Syndromes in cardiology

Cardiological contraindications to physical exercise

The clearance of patients with heart disease for physical exertion depends on the severity of hemodynamic and structural changes. Exercise is strictly contraindicated in the following conditions:

• Acute structural changes: acute coronary syndrome (ACS), acute and subacute left ventricular aneurysms, aortic dissection, and the presence of intracardiac thrombi.
• Inflammatory processes: acute myocarditis, pericarditis, and endocarditis.
• Hemodynamic decompensation: heart failure functional class IV according to the NYHA classification, uncontrolled arterial hypertension (resting BP above 180/110 mmHg), severe aortic stenosis, and severe obstructive hypertrophic cardiomyopathy.
• Electrical instability: syncopal states, high-grade ventricular extrasystole and tachycardia, and paroxysms occurring during exertion. The restriction also applies to grade 2–3 sinoatrial and AV blocks (with the exception of patients with an already implanted pacemaker).

In addition, restrictions apply to severe comorbidities (uncontrolled diabetes mellitus, acute infections) and are temporarily imposed following vascular events—strokes, transient ischemic attacks, or thrombophlebitis (within 3 months).

Age-related evolution of cardiological syndromes in children

The symptomatology of cardiovascular diseases changes dramatically as a child grows. What manifests as pain or arrhythmia in adults looks different in infants.

1. Neonates. Cyanosis (bluish discoloration of the lips, ears, and skin), which may be constant or occur only during crying and feeding, helps suspect congenital heart disease (CHD). Pallor, cold extremities, shortness of breath (tachypnea), failure to thrive, and edema (abdominal, lower extremities, periorbital) are also characteristic. Objective examination reveals tachycardia and pathological murmurs.
2. Infancy and early childhood. The clinical picture becomes enriched with signs of cardiac chamber overload. For example, a combination of cyanosis, shortness of breath during feeding, tachycardia approaching 140 bpm, and a harsh systolic murmur requires differentiating septal defects (VSD, ASD), coarctation of the aorta, or Tetralogy of Fallot.
3. Adolescents. "Adult" complaints of heart fluttering are extremely rare. During puberty, the clinical picture is masked by psychovegetative shifts: cardialgia, insomnia, and hyperexcitability predominate. Life-threatening arrhythmias (AV blocks, paroxysmal tachycardias) manifest with symptoms of impaired cerebral blood flow—weakness, dizziness, and syncope. In obstructive defects (coarctation of the aorta), complaints are associated with systemic ischemia: pain in the legs and abdomen, headaches.

Differential diagnosis of non-rheumatic carditis

When diagnosing non-rheumatic carditis in older children, it is necessary to exclude a number of nosologies with a similar presentation. The diagnostic search is built along four vectors:

• Rheumatic fever (acute rheumatic fever). Manifests after 7 years of age and has a clear link to streptococcal infection. The main topographical distinction: rheumatic fever affects both the endocardium and myocardium, leaving acquired heart defects, whereas carditis involves isolated myocardial injury. Extracardiac manifestations (Sydenham's chorea, polyarthritis) are present.
• Extracardiac arrhythmias. Occur against the background of autonomic dysfunction or central nervous system disorders (including perinatal history). They are characterized by high symptom variability and the complete absence of organic heart damage.
• Myocardial dystrophy. A secondary condition resulting from infections, intoxications, or endocrinopathies. Symptoms are sparse, and heart size is not altered. The key criterion is the regression of cardiological signs upon successful treatment of the underlying disease.
• Cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is familial in nature with no connection to infections. Echocardiography reveals asymmetric septal hypertrophy with preserved myocardial contractility and normal cavities, while auscultation reveals a subaortic stenosis murmur.

Additionally, the differential diagnosis includes mitral valve prolapse, connective tissue dysplasias, autonomic dysfunction syndrome with ST-segment and T-wave changes, and long Q-T syndrome.

Class and exam questions

What else to study on this topic

• Gradations of hemodynamic disorders and heart failure.
• Clinical and auscultatory patterns of congenital heart defects in young children.
• ECG patterns in functional disorders: ST-segment changes and long QT syndrome.
• Criteria for diagnosing hypertrophic cardiomyopathy based on echocardiography.
• Two-stage regimen and principles of therapy for non-rheumatic carditis.

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