Maria Shkolnikova: “Russia has one of the highest mortality rates from cardiovascular diseases. The released hostage Maria Shkolnikova tells

Scientific Supervisor (Director of the Institute from February 2014 to November 2016), Doctor medical sciences, Professor Shkolnikova Maria Alexandrovna – leading pediatric cardiologist in Russia, famous scientist and organizer of medical science, student of the founder of the modern Russian School of Pediatric Cardiologists - Professor Belokon Natalia Alekseevna. Shkolnikova M.A. graduated from the pediatric faculty of the 2nd Moscow medical institute them. N.I. Pirogov (currently Russian National Research Medical University named after N.I. Pirogov of the Ministry of Health of the Russian Federation). Then she was trained in clinical residency in pediatrics at the same university. In 1984 - 1987 she studied at the full-time postgraduate course of the Moscow Research Institute of Pediatrics and Pediatric Surgery of the Ministry of Health of the Russian Federation (now the NIKI of Pediatrics RNIMU named after N.I. Pirogov - hereinafter referred to as the Institute), in 1987 she defended her Ph. non-paroxysmal tachycardia in children and approaches to rational therapy"(head prof. Belokon N.A.) in the specialty" Pediatrics ". In 1993 she defended her doctoral dissertation on the topic “Predicting the risk of developing life-threatening conditions and sudden death in children with cardiac arrhythmias, principles of prevention” (consultant academician Yu.E. Veltishchev). Since 1987, she has been continuously working at the Institute, having gone from researcher to chief researcher, head of the children's scientific and practical center for cardiac arrhythmias, and finally, director of the Research Institute of Pediatrics. Prof. M.A. Shkolnikova is the president of one of the most numerous specialized professional medical associations- All-Russian public organization "Association of Pediatric Cardiologists of Russia", uniting more than 2,000 pediatric cardiologists from all regions of the Russian Federation.

For more than 20 years, under her leadership, fundamental and applied Scientific research on the study of pathophysiological mechanisms, features of the clinical course, the development of treatment methods and criteria for predicting cardiac arrhythmias in children; The functional-diagnostic direction in pediatrics is successfully developing. Her ongoing research into developmental risk factors and markers sudden cardiac death and life-threatening arrhythmias in children have been widely recognized, both in Russia and at the international level, have formed the basis of new effective high-tech methods of diagnosis and treatment. Under the leadership of M.A. Shkolnikova in the Russian Federation introduced molecular genetic studies of children with life-threatening arrhythmias and their families, which made it possible to establish genetic variants of a hereditary pathology associated with a high risk of sudden death. She has developed and implemented her own effective methods of therapeutic treatment and prevention of life-threatening tachyarrhythmias and bradyarrhythmias in children and young people, long QT syndrome, and prevention of sudden infant death syndrome. Indications for cardiac surgical correction of arrhythmias in children, risk criteria for cardiogenic attacks of loss of consciousness and sudden cardiac death have been developed; a system for monitoring risk factors for sudden cardiac death in children with cardiac arrhythmias was created; developed and implemented an algorithm for family examination and observation in cases hereditary forms life-threatening arrhythmias. The introduction of these methods of diagnostics and treatment made it possible to achieve the recovery of 93% of children with tachyarrhythmias and reduce the mortality of children with life-threatening arrhythmias by 10 times.

Shkolnikova Maria Alexandrovna for many years has been the organizer and coordinator of the development of one of the fastest growing and high-tech areas of pediatrics - pediatric cardiology. For more than 15 years M.A. Shkolnikova was the chief pediatric cardiologist of the Ministry of Health of the Russian Federation. With her direct participation, "children's cardiology" became one of the independent specialties in Russia, requiring in-depth training, which made it possible to focus the attention of specialists on the need to master and widely implement a large amount of special knowledge and skills, according to modern high requirements to specialists in this field.

Prof. M.A. Shkolnikova is the chief expert pediatric cardiologist of the Moscow Department of Health, laureate of the Lenin Komsomol Prize for medicine, laureate of the Moscow Mayor's Prize for the developed methods for diagnosing and preventing sudden cardiac death in children. Maria Alexandrovna is the author of a number of inventions and patents. Under the leadership of M.A. Shkolnikova defended 17 candidate and 3 doctoral dissertations. She is the author of more than 300 publications (including more than 100 published in foreign press), 11 monographs and 39 chapters in monographs, 33 methodological recommendations of the Ministry of Health of the Russian Federation and the Moscow Department of Health. She lectures annually and hosts workshops and seminars with medical residents and pediatricians on the examination and treatment of patients with cardiac pathology. He actively works with young employees, educating a school of young specialists in Russia, continuing the work of Professor Belokon N.A. Among her students are talented doctors, heads of clinics, heads of pediatric departments, chief specialists - pediatric cardiologists in various regions of Russia, famous scientists, healthcare organizers. Many of them have won recognition not only in our country, but also abroad, annually receiving prestigious professional awards at all-Russian and international congresses.

M.A. Shkolnikova is the organizer of 8 All-Russian Congresses "Pediatric Cardiology", she is the national representative of Russia in the European Association of Pediatric Cardiology, a member of the board Russian Society arrhythmologists, a member of the European Society of Arrhythmology and the European Association of Cardiology, as well as a number of other public organizations. Currently a member of the editorial boards of 3 pediatric and 2 cardiology journals.

Some publications.

Chief Freelance Pediatric Specialist Cardiologist of the Moscow City Health Department, Head of the Department of Cardiology, GBUZ Children's City Clinical Hospital. PER. Bashlyaeva DZM", Doctor of Medical Sciences, Professor

Biography

Education:

In 1999 she graduated from the Ryazan State Medical University. Acad. I.P. Pavlova with a degree in General Medicine. After graduating from the university, she underwent clinical residency in the specialty "Cardiology" (1999-2001) and postgraduate studies (2001-2004) on the basis of the Scientific Center for Cardiovascular Surgery. A.N. Bakuleva RAMS. From 2004 to 2013, she worked in the Department of Intensive Cardiology of Premature and Infants with Congenital Heart Diseases of the Scientific Center for Cardiovascular Surgery of the Russian Academy of Medical Sciences, successively as a junior researcher, researcher, and then senior researcher.

In 2006, on the basis of the Scientific Center for Cardiovascular Surgery. A.N. Bakulev, defended a dissertation for the degree of candidate of medical sciences on the topic "Rhythm and conduction disorders of the heart in newborns and infants" in the specialties "Cardiology" and "Cardiovascular Surgery". In 2008, she specialized in pediatric cardiology and ultrasound diagnostics at Ospedale Riuniti, Bergamo (Italy). In 2013, the Academic Council of the Scientific Center for the Union of Artists named after. A.N. Bakulev was awarded academic degree doctor of medical sciences. The dissertation work was done on the topic "Risk factors for surgical treatment of congenital heart defects in the group of newborns".

From 2013 to the present, he has been working as a pediatric cardiologist, head of the cardiology department of the Children's City Clinical Hospital named after S. Bashlyaeva Z.A. Moscow Health Department. From 2014 to 2018 she was the district cardiologist of the Northwestern administrative district Moscow. In 2016, she was the winner of the Formula of Life competition, established by the Moscow Department of Health, where she was awarded the award in the Best Cardiologist nomination.

He has diplomas in the specialties: "Pediatrics", "Pediatric cardiology", "Neonatology", "Ultrasound diagnostics", "Functional diagnostics".

Since 2011 - doctor the highest category majoring in Pediatric Cardiology.

From 2007 to 2013 - Assistant at the Department of Cardiovascular Surgery with a course in Interventional Cardiology of the Faculty postgraduate education Moscow State University of Medicine and Dentistry. A.I. Evdokimov. From 2013 to the present, he has been a professor at the Department of Hospital Pediatrics. V.A. Tabolin, Faculty of Pediatrics, Russian National Research Medical University. N.I. Pirogov of the Ministry of Health of Russia.

Speaks English, French and Italian.

Information about plans for 2018 in the direction of "Pediatric cardiology"

  • Creation of the organizational method of the Department of Pediatric Cardiology
  • Holding monthly educational seminars for doctors (outpatient and inpatient level - pediatricians, pediatric cardiologists, neonatologists, functional and ultrasound diagnostics)
  • Optimization of work towards early detection of children with CHD. Strengthening control over the correct performance of neonatal screening in maternity hospitals and perinatal centers in Moscow (together with the Chief Neonatologist and Chief Cardiac Surgeon)
  • Holding events dedicated to world day hearts (September 30)
  • Participation in the work of specialized congresses, assemblies, symposiums, congresses.

    Brief information about the work in 2018 of a freelance specialist of the DZM chief pediatric cardiologist, Doctor of Medical Sciences, Trunina I.I.

    1. Photography:

    2. Full name of the position at the main place of work: Trunina Inna Igorevna - Doctor of Medical Sciences, Head of the Department of Cardiology, GBUZ Children's City Clinical Hospital named after I.I. Bashlyaeva Z.A. DZM, Professor of the Department of Hospital Pediatrics. V.A. N.I. Pirogov" of the Ministry of Health of the Russian Federation; member of the All-Russian public organization "Association of Pediatric Cardiologists of Russia".

    3. About having a network of district specialists In the city of Moscow, under the leadership of the chief freelance specialist, the pediatric cardiologist of Moscow, a network of district pediatric cardiologists operates in 11 districts of the city.

    county Full name Medical organization
    SZAO Telezhnikova Natalya Dmitrievna pediatric cardiologist GBUZ "Children's City Clinical Hospital. PER. Bashlyaeva" DZ of Moscow
    Company Alyamovskaya Galina Nikolaevna pediatric cardiologist GBUZ "Children's City Polyclinic No. 131 DZ of Moscow"
    ZeLAO Gromova Tatyana Gennadievna pediatric cardiologist GBUZ "Children's City Polyclinic No. 105 DZ Moscow"
    SEAD Efimov Sergey Vladimirovich pediatric cardiologist GBUZ "Children's City Polyclinic No. 150, Branch No. 1 of the Department of Health of Moscow",
    SVAO Zubrilina Svetlana Evgenievna Deputy chief physician for clinical and expert work, pediatric cardiologist GBUZ "Children's City Polyclinic No. 110 DZ Moscow"
    TiNAO Ivanova Svetlana Vladimirovna Candidate of Medical Sciences, Pediatric Cardiologist, Functional Diagnostics Doctor GBUZ Moscow "Scientific and Practical Center for Specialized medical care children named after V.F. Voyno-Yasenetsky DZ of Moscow"
    SAO Ivushkina Elena Viktorovna pediatric cardiologist GBUZ "Children's City Polyclinic No. 129 DZ of Moscow.
    SWAD Kiladze Elena Sergeevna pediatric cardiologist GBUZ "Children's City Polyclinic No. 69DZ of Moscow".
    CAO Moreno Ilya Gennadievich Candidate of Medical Sciences, Head of the Department of Cardiology GBUZ "Children's City Clinical Hospital of Children's City Clinical Hospital No. 9 named after I. G.N. Speransky Department of Health of Moscow"
    SAO Pavlova Evgenia Stanislavovna Ph.D., head of the consultative and diagnostic department GBUZ Moscow "Children's infectious diseases clinical hospital No. 6 DZ Moscow"
    HLW Tikhomirova Yulia Sergeevna pediatric cardiologist GBUZ Moscow "Children's City Polyclinic No. 122 DZ Moscow" Branch No. 1

    4. Brief information about the work in 2017 and work plans for 2018 in the specialty "pediatric cardiology"
    No. p / p Achievements in the relevant profile Achieved positive effects from the implementation.
    1. The Federal State Educational Standard (FSES) has been developed in the specialty "children's cardiology" The GEF project was developed by the All-Russian public organization "Association of Pediatric Cardiologists of Russia", approved by the Union of the Medical Community "National Medical Chamber" and the Ministry of Health of the Russian Federation, submitted for consideration to the Ministry of Labor of the Russian Federation.
    2. Approval by the Ministry of Health of the Russian Federation of Clinical recommendations for the diagnosis and treatment of diseases of the cardiovascular system in children - the area of ​​competence of pediatric cardiologists (website http://cr.rosminzdrav.ru) The introduction of clinical guidelines contributes to the standardization of the management of children with cardiovascular diseases based on evidence-based medicine.
    3. A program of continuous vocational education pediatric cardiologists in Moscow based permanent Seminar with the chief specialist, a pediatric cardiologist in Moscow. The seminar includes analysis of clinical cases with the participation of leading specialists from city and federal medical institutions. The purpose of the seminar: to improve the quality of medical care for children in Moscow with diseases of the cardiovascular system based on continuous advanced training of cardiologists, doctors of functional diagnostics, specialists in the field of ultrasound diagnostics of heart and vascular diseases. In 2018, 10 seminars were held on hot topics in pediatric cardiology.
    5. A series of lectures (3 lectures) for residents of modern principles diagnosis and treatment of heart diseases in children at the Russian National Research Medical University. Pirogova N.I. (Moscow). Acquisition of up-to-date knowledge in pediatric cardiology, aimed at further improvement of professional knowledge and skills in order to maintain a high modern level of training within the framework of residency in pediatrics.
    6. Webinar (2 webinars) for neonatologists as part of continuous educational seminars Informing neonatologists on morbidity, early detection of cardiovascular pathology and modern approaches to therapy in newborns and premature babies.
    7. Seminar for neonatologists within the framework of educational seminars of the Neonatology section of the Moscow Society of Pediatric Doctors Training of neonatologists in the basic principles of neonatal screening for congenital heart defects, the diagnosis of life-threatening cardiac arrhythmias, and the basic principles of treatment and routing of newborns with cardiovascular pathology
    8. Organization and holding international day hearts in Moscow. one). Round table, lectures for pediatricians and pediatric cardiologists. 2). School of health for parents, consultations of leading children's cardiologists in Moscow. The purpose of the action is to increase attention to the prevention of cardiovascular diseases in various age groups population. It is held under the motto: "Heart for life".
    9. Organization and holding of the X Anniversary All-Russian Congress of Pediatric Cardiologists About 400 specialists from 80 regions of Russia (more than 50 from Moscow) took part in the program. The reports summarized Russian and international experience in the diagnosis and treatment of congenital heart defects, orphan pathology, life-threatening arrhythmias, and rare forms of cardiomyopathies http://www.cardio-rus.ru/
    10. Implementation of the program Neonatal screening for congenital heart defects in maternity hospitals continued, according to previously prepared methodological recommendations Moscow Health Department Early diagnosis of critical congenital heart defects at the stage of the maternity hospital. Continuity between maternity hospitals and specialized hospitals with cardiological beds in the state in the introduction of newborns with congenital heart defects and their further observation. Reduction in the number of late diagnosed patients with critical congenital heart defects
    11. Released educational edition"Pediatric cardiology", 2018 (co-author) The publication presents a wide range of cardiovascular diseases relevant to childhood, outlines modern diagnostic approaches and algorithms, criteria for diagnosis and drug treatment regimens.
    12. The book for parents "Three main years" was released, 2018 (co-author) Popularization of knowledge of the general public in the field of pediatrics, the main diseases characteristic of children in the first three years of life. The features of child care, their development and upbringing are outlined.
    13. Carrying out accreditation in pediatrics at the Russian National Research Medical University. N.I. Pirogov of the Ministry of Health of Russia Member of the Accreditation Commission of the Ministry of Health
    14. Conducting field consultations in Gudermes Chechen Republic Identification of children with cardiovascular pathology and adjustment of the therapy. The goal is to increase the availability of medical care in the cities of the Russian Federation. The program was developed jointly with the Center for Assistance to Affected Children
    15. Participation in the preparation of a methodological manual for an outpatient pediatrician on a number of nosologies relevant to children Implementation of the program of the Moscow Health Department
    16. Participation in the finalization of the list of medical indications for sanatorium treatment of the children's population and the list of medical contraindications for sanatorium treatment. As part of the work to improve the existing regulatory legal framework, proposals were prepared for the draft order of the Ministry of Health of Russia “On Amendments to the Order of the Ministry of Health of the Russian Federation of May 5, 2016 No. 281n “On Approval of Lists of Medical Indications and Contraindications for Spa Treatment”, which provides for the expansion of lists of medical indications for certain diseases.
    17. Committee working group meeting State Duma on health protection "On improving the regulatory legal regulation medical care in preschool educational organizations and general education organizations. Participation.
    18. Work with the media - TV channel "Doctor" topic: "The state of the cardiovascular system of the child" (popularization of knowledge for parents and children about the features of the development of the cardiovascular system of the child).
    19. Work in open areas in social networks in the Internet. - Site of the hospital. Bashlyaeva Z.A. DZM http://www.tdgb-mos.ru - Website of the VOO "Association of Children's Cardiologists of Russia" http://www.cardio-rus.ru/ - Website of the DZ of the city of Moscow
    20. Work with public organizations. - Work on issues of "Children's Health" with patient organizations: 1. Action "Take care of your heart from childhood" - Day open doors with the participation of cardiologists; 2. Schools for parents "Prevention of cardiovascular diseases in children", "Prevention of arterial hypertension", "Congenital heart defects in children, how to improve the quality of life" in the departments (offices) of medical prevention of polyclinics of the State Budgetary Health Institution of Moscow; four. Offsite events in preschool and school institutions with counting heart rate, measuring blood pressure, conducting an ECG.
    21 All children in Moscow with orphan pathology were reconciled. I27.0 Pulmonary hypertension. Children are included in the regional segment of the Federal Register, and preferential drug coverage for newly included children has been established. Improving the quality of life and medical care for children with orphan pathology
    In hospitals and clinics in Moscow, the provision of medical care to children and adolescents with diseases of the cardiovascular system is being improved, taking into account modern international standards and the principles of evidence-based medicine.

    Implemented:
    1. Highly effective technologies for diagnosing cardiovascular diseases and their complications in childhood, including prenatal and early postnatal diagnostics (non-invasive electrocardiographic diagnostics, Doppler echocardiography, including vascular and tissue Doppler; imaging methods - MRI, CT; stress tests; tilt test , long-term ECG monitoring, including Holter, seven-day and long-term (up to 3.5 years) based on implantable Revil devices; invasive methods for studying the heart and blood vessels; methods for studying myocardial metabolism; determination of inflammation markers; analysis of immune mechanisms for the development of heart diseases; research nervous regulation with violations of cardiac activity; molecular genetic studies, etc.). Technologies such as doppler echocardiography, stress tests, ECG Holter monitoring, invasive electrophysiological studies of the heart, and a number of others have become an integral part of the standard clinical diagnosis of various diseases of the cardiovascular system in children. A three-level therapy for life-threatening ventricular arrhythmias is being introduced into practice: 1. Antiarrhythmic therapy. 2. Implantable antiarrhythmic devices. ICD therapy - repeated syncope on therapy with beta-blockers; initially high risk of SCD, concentration of cases of sudden death in the family. Satisfactory control of the arrhythmia with beta-blockers should be achieved. 3. Left-sided sympathectomy - frequent ICD triggering in patients with SUIQT, provocation of SVT by exercise during therapy with beta-blockers. It is necessary to establish timely detection of children with long QT-interval syndrome, to develop screening.
    2. Treatment technologies are being introduced, including surgical and minimally invasive ones, which are especially intensive in last years develop in relation to cardiac arrhythmias, congenital heart defects, cardiomyopathies, pulmonary hypertension: technologies for 3D anatomical reconstruction of the heart using contrast in the interventional treatment of tachyarrhythmias; video-assisted thoracoscopy technique for implantation of epicardial electrodes with active fixation (the technology is used for the first time); left-sided sympathectomy by thoracoscopic access in patients at high risk, as well as those who have undergone sudden cardiac arrest.
    3. Modern methods of training and professional retraining of specialists - pediatric cardiologists (based on residency in the specialty "pediatric cardiology" and advanced training courses), taking into account European and international standards, continuous training (credit system), interactive learning, the creation of accessible large-scale resources. A new professional standard for a pediatric cardiologist is being introduced, in terms of accreditation of hospital and outpatient specialists.
    4. A federal register of life-threatening arrhythmias is maintained, which makes it possible to provide all the necessary types of specialized medical care to these categories of patients in a timely manner. 86 pediatric cardiologists work in 121 polyclinics of the city. According to the procedure for providing medical care to children with cardiac pathology, standards are provided at the rate of 1 specialist pediatric cardiologist per 20,000 children. Accordingly, the need for specialists - pediatric cardiologists is 95 people. It is noteworthy that in a number of polyclinics there are no pediatric cardiologists. Patients attached to these polyclinics are examined and consulted in the district APC, in city clinics (GBUZ "DGKB named after Z.A. Bashlyaeva DZ of the city of Moscow", GBUZ "Children's City Clinical Hospital of the Children's City Clinical Hospital No. 9 named after G.N. Speransky" DZ city ​​of Moscow, GBUZ DGKB No. 13 named after N.F. Filatov), ​​where there are specialized cardiology departments. The appointment time of a pediatric cardiologist is limited to a 15-minute appointment, which is not enough in the absence of a nurse working at the reception together with a cardiologist.

    Rehabilitation of children with cardiovascular pathology was carried out on the basis of a specialized cardio-rheumatological sanatorium No. 20 "Krasnaya Pakhra" for 220 beds for children from 4 to 14 years old and a sanatorium-forest school No. 4 in Bykovo for 120 beds. Currently, rehabilitation is available in 43 Sosnovy Bor sanatoriums.
    Scientific work is carried out mainly on the basis of departments that cooperate with research institutes, for example, FSBEI HE “RNIMU named after N.I. N.I. Pirogov" of the Ministry of Health of the Russian Federation, FGBOU DPO "Russian Medical Academy of Continuous Professional Education" of the Ministry of Health of the Russian Federation and others. The results of the research are presented to the medical community at the meetings of the Moscow City Society of Pediatric Doctors (cardio-rheumatological section and plenary meetings), the Assembly "Health of the Capital", the city congress of pediatricians "Difficult Diagnosis", monthly seminars and others. The city's specialists actively cooperate with the above research bases.

    Moscow Children's Cardiology Service Development Plan for 2019

    1. Personnel policy. In 2019, it is necessary to train 14 specialists - pediatric cardiologists on the basis of residency in this specialty, followed by employment at the Moscow AC.
    2. Continuing Postgraduate Education for Physicians- pediatric cardiologists on the basis of a permanent seminar and the Moscow City Society of Pediatric Doctors. A permanent seminar for pediatric cardiologists and specialists in ultrasound diagnostics of cardiovascular diseases for in-depth study of cardiac imaging methods - expert echocardiography, MRI and CT, which is necessary to expand the possibilities of diagnosing cardiovascular pathology in children at the city hospitals. In 2019, it is planned to introduce a system of "credits", distance education. The plan for 2019 includes educational seminars for pediatricians from all districts of Moscow on the topic “Basic principles for diagnosing and routing newborns and children with diseases of the cardiovascular system”.
    3. Revision and improvement of the neonatal screening program for congenital heart defects in Moscow. Training of neonatologists and nurses of maternity hospitals in methods of early diagnosis of critical CHD.
    4. Approval of clinical guidelines on the diagnosis and treatment of diseases of the cardiovascular system in children. Planned further work according to the statement a wedge of recommendations on separate nosologies.
    5. Monitoring system coverage patients with high pulmonary hypertension in all districts of the city of Moscow, the introduction of the register.
    6. Introduction into the outpatient network of screening to identify children with elongatedQT-interval. Improving the system for early detection of life-threatening arrhythmias in children and early diagnosis of the causes of seizures of loss of consciousness in children (seminares with pediatric cardiologists, an information letter for polyclinics, maternity hospitals, preschool institutions and schools are planned).
    7. Organization and conduct "International Heart Day in Moscow": 1. Round table, lectures for pediatricians and pediatric cardiologists. 2. School of health for parents, consultations of Moscow's leading pediatric cardiologists as part of an annual city event with the involvement of the main freelance pediatric cardiologists of the Moscow City Health Department.

    Plan educational and information events scheduled for 2019 with the support of the Department of Health of the city of Moscow

    specialty number Type of event (congress, forum, conference, seminar, master class, training, webinar, etc.) Name of the event Form of study Goals and objectives of the event Target audience (heads of institutions, doctors, nurses, related specialists) Number of participants Duration Periodicity (number per year)
    1 Seminar full-time Pediatricians and neonatologists of SZAO 50 2 hours 11 (16.01.2019)
    2 Seminar Left ventricular dysfunction. Analysis of complex clinical cases from the practice of a pediatric cardiologist. full-time Raising the level of education of pediatric cardiologists, pediatricians 50 2 hours 1 (23.01.2019)
    3 Seminar Modern look Problem: Acute rheumatic fever full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50 2 hours 1 (13.02.2019)
    4 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the SWAO 50 2 hours 11 (20.02.2019)
    5 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of SVAO 50 2 hours 11 (20.03.2019)
    6 Seminar Electrocardiostimulation in children. Indications for pacemaker implantation and management of children of different ages with implanted devices full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50 2 hours 1 (27.03.2019)
    7 Seminar Kawasaki syndrome, management tactics for convalescents (Lyskina G.A.) Instrumental diagnosis of heart and vascular lesions in Kawasaki syndrome (Shirinskaya O.G.) Kawasaki syndrome based on the results of observation in the rheumatology department of the MDCH full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50 2 hours 1 (10.04.2019)
    8 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the TiNAO 50 2 hours 11 (17.04.2019)
    9 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the Eastern Administrative Okrug 50 2 hours 11 (15.05.2019)
    10 Seminar Coding for cardiovascular disease in children. Controversial and complex issues full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50 2 hours 1 (22.05.2019)
    11 Seminar XI All-Russian Seminar "Congenital Heart Diseases: Possibilities for Diagnosis, Treatment and Rehabilitation", dedicated to memory outstanding pediatric cardiologist, professor N.A. Belokon.Schools-seminars on pediatric cardiology full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 500 2 -3 days 1 (July)
    12 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of SEAD 50 2 hours 11 (17.07.2019)
    13 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the South Administrative District 50 2 hours 11 (21.08.2019)
    14 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the SAO 50 2 hours 11 (18.09.2019)
    15 Seminars, master classes, round table Round table dedicated to the day of the heart. Difficulties in diagnosing diseases of the cardiovascular system in children at the outpatient stage full-time Improving the quality of medical care in the city of Moscow, improving professional knowledge, discussing clinical cases, and exchanging opinions. District cardiologists of Moscow, heads of healthcare facilities, pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50-70 3 hours 1 (25.09.2019)
    16 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of Zelenograd Autonomous Okrug 50 2 hours 11 (17.10.2019)
    17 Meeting within the framework of the congress Meeting within the framework of the 5th Moscow City Congress of Pediatricians “Difficult Diagnosis in Pediatrics” School-seminars on pediatric cardiology. full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 500 3 days 1 (October-November)
    18 Congress, School-seminar 18th Russian Congress "Innovative Technologies in Pediatrics and Pediatric Surgery" with international participation. School-seminars on pediatric cardiology. full-time Improving the quality and accessibility of medical care provided to the children's population of Moscow, including specialized, by expanding medical knowledge in all areas of pediatrics and pediatric surgery. Healthcare organizers, pediatric cardiologists, cardiovascular surgeons, resuscitators, general practitioners, local pediatricians, gastroenterologists, pulmonologists, etc. Around 1500 3 days 1 (20th of October)
    19 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists of the Central Administrative District 50 2 hours 11 (20.11.2019)
    20 Seminar Surgical anatomy of the heart. What a Pediatric Cardiologist Needs to Know full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50 2 hours 1 (27.11.2019)
    21 Seminar Basic principles of diagnosis and routing of newborns and children with diseases of the cardiovascular system full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatricians and neonatologists CJSC 50 2 hours 11 (18.12.2019)
    22 Seminar Echocardiographic diagnosis of diseases of the cardiovascular system in children. Basic approaches. Study protocol. full-time Raising the level of education of pediatric cardiologists, pediatricians Pediatric cardiologists, pediatricians, neonatologists, functional diagnostics doctors 50
  • Shkolnikova Maria Alexandrovna

Keywords

CHILDREN / SUDDEN DEATH/ HEART ARRHYTHMIAS / SPORTS / PREVENTION

annotation scientific article on medicine and health care, author of scientific work - Shkolnikova Maria Aleksandrovna

Young athletes are considered the healthiest part of society, while at the same time they have cases every year. sudden death caused, as a rule, by life-threatening arrhythmias. Sudden death from arrhythmia in athletes most often develops against the background of an already existing, but not diagnosed, organic heart disease. A number of high-risk pathological conditions have been identified sudden death with anatomically normal heart: Wolff-Parkinson-White syndromes, long and shortened Q-T interval, etc. Among the factors affecting the risk of cardiovascular complications in sports in children with heart rhythm disturbances, the specifics of arrhythmia, its possible pathophysiological consequences, as well as the overall reaction of the cardiovascular system to stress, due to sports load. A differentiated approach to solving the issue of competitive sports in children without organic heart disease, with various types of arrhythmias, is presented. A plan for the examination of the child was recommended, clinical and electrophysiological criteria for the risk of adverse complications during sports were given, permitted sports and the frequency of observation were determined.

Related Topics scientific works on medicine and public health, the author of scientific work - Shkolnikova Maria Aleksandrovna,

  • Sports and sudden death in children

    2017 / Makarov Leonid Mikhailovich

  • Sudden cardiac death in children. Part 2

    2013 / Pshenichnaya E.V.

  • Sudden cardiac death in older athletes

    2016 / Tsareva Marina Olegovna, Schwartz Yuri Grigorievich

  • Ventricular arrhythmias in young elite athletes

    2015 / Komoliatova Vera Nikolaevna, Makarov L.M., Fedina N.N., Kiseleva I.I., Bessportochny D.A.

  • Sudden cardiac death in children and adolescents diagnostic problems. Directions of prevention (literature review)

    2013 / Nikonova V. V.

The text of the scientific work on the topic "Cardiac arrhythmias and sports - the brink of risk"

Cardiac arrhythmias and sports are at risk

M.A. Shkolnikova

Cardiac arrhythmias and sports - the verge of a risk

M.A. Shkolnikova

Moscow Research Institute of Pediatrics and Pediatric Surgery;

Children's Scientific and Practical Center for Heart Rhythm Disorders, Moscow

Young athletes are considered the healthiest part of society, while at the same time they have sudden deaths every year, usually due to life-threatening arrhythmias. Sudden death from arrhythmia in athletes most often develops against the background of an already existing, but not diagnosed, organic heart disease. A number of pathological conditions with a high risk of sudden death in an anatomically normal heart have been identified: Wolff-Parkinson-White syndromes, long and short Q-Ti intervals, etc. Among the factors affecting the risk of cardiovascular complications in sports in children with heart rhythm disturbances , the specifics of arrhythmia, its possible pathophysiological consequences, as well as the general reaction of the cardiovascular system to stress due to sports load are of primary importance. A differentiated approach to solving the issue of competitive sports in children without organic heart disease, with various types of arrhythmias, is presented. A plan for the examination of the child was recommended, clinical and electrophysiological criteria for the risk of adverse complications during sports were given, permitted sports and the frequency of observation were determined.

Keywords: children, sudden death, cardiac arrhythmia, sports, prevention.

Young athletes are considered to be the healthiest part of society, at the same time among them there are annually notified cases of sudden death generally caused by life-threatening arrhythmias. Sudden death from arrhythmia in athletes most frequently occurs in the presence of an already existing, but undiagnosed, organic cardiac lesion. A number of pathological conditions with a high risk of sudden death in the anatomically normal heart: Wolff-Parkinson-White syndrome, prolongation or shortened Q-T interval, etc. have been identified. Among the factors influencing the cardiovascular risk in children with cardiac arrhythmias on doing sports, the specific features of arrhythmia, its possible pathophysiological sequels, and an overall cardiovascular response to sports load-induced stress are of fundamental importance. A differential approach to solving the problem associated with doing different contest sports in children without organic cardiac diseases, who have various arrhythmias, is presented. A plan for examination of a child is recommended; the clinical and electrophysiological criteria for the risk of poor complications on doing sports are given; the permitted sports and the frequency of an observation are defined.

Key words: children, sudden death, cardiac arrhythmias, sports, prevention.

AT modern life for many teens, "going in for sports" means feeling like a full member of society. For children with certain diseases or developmental features, modern medical technologies allow them to correctly orient themselves in choosing a safe sports load. A special place in this problem is occupied by cardiac arrhythmias due to both their prevalence in the child population and the fact that sudden death during sports in 90% of cases is due to cardiac arrhythmias. The prognosis for the natural course of rhythm disturbances varies from absolutely favorable to severe, associated with the risk of developing life-threatening complications. To address the issue of the safety of the competition

© M.A. Shkolnikova, 2010

Ros Vestn Perinatol Pediat 2010; 2:4-12

Address for correspondence: Shkolnikova Maria Aleksandrovna - Doctor of Medical Sciences, Prof., Head. Children's Scientific and Practical Center for Cardiac Arrhythmias on the basis of the Moscow Research Institute of Pediatrics and Pediatric Surgery 125412 Moscow, st. Taldomskaya, 2

sports for children with certain arrhythmias should be approached taking into account modern ideas about the pathogenetic mechanisms of arrhythmias, risk factors, prognosis and modern possibilities for correction.

Young athletes are traditionally considered to be the healthiest part of society, while at the same time, sudden deaths are recorded among them every year. Most often, sudden death from arrhythmia in athletes occurs against the background of an already existing but not diagnosed organic heart disease: hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, anomalies of the coronary arteries, myocarditis, congenital heart disease. A number of pathological conditions with a high risk of sudden death due to life-threatening ventricular arrhythmias that develop in individuals with anatomically normal hearts have been identified: Wolff-Parkinson-White syndromes, long and shortened QT interval, Brugada, as well as dysfunction of the sinus node and atrioventricular

lar conduction, intraventricular blockade and commotio cordis. In some cases, the cause of sudden death remains unclear, despite a detailed pathomorphological examination.

Sports include not only physical, but also emotional stress, which places increased demands on the child's body. Among people who are intensively involved in sports, the risk of sudden death is 2 times higher and is 1.6 per 100,000 versus 0.75 per 100,000. Identification of the risk of inadequate response to the load from various bodies and body systems, and especially on the part of the cardiovascular system, is within the competence of the doctor who decides on the admission of the child to sports in general and each specific sport in particular. The decision is based on the data of the preliminary examination, the volume of which should be expanded, if necessary, depending on the identified deviations and anamnesis data. In some cases, sports may not be recommended. The tactic currently adopted is to expand, according to previously identified changes, the examination protocol, the results of which provide the key to assessing the degree of risk, allow you to reasonably recommend or not recommend the child to practice this or that sport and determine the possibility of admission to the competition.

pits. This approach in children with cardiac arrhythmias reduces the risk of complications and avoids sudden cardiac death.

Prevention of sudden death during sports is based on: 1) preliminary medical examination a future athlete with an emphasis on the analysis of the state of the cardiovascular system; 2) providing affordable and qualified cardiopulmonary resuscitation in places of intensive training and competition, including automatic external cardioverter defibrillators; 3) maintaining national and international registries of cases of sudden death of athletes.

Rhythm disturbances occupy the second place, after congenital heart defects, in the structure of cardiovascular diseases in childhood (see figure). In most cases, in children, cardiac arrhythmias develop in the absence of obvious signs of organic heart damage, and the only diagnosis is arrhythmia, most often extrasystole, paroxysmal or non-paroxysmal supraventricular tachycardia, sick sinus syndrome, ventricular tachyarrhythmias. In childhood, heart rhythm disturbances also occur as a complication of congenital heart defects, infective endocarditis, cardiomyopathy, carditis and other diseases.

Picture. Classification of clinically significant cardiac arrhythmias in children.

% of patients of this group of arrhythmias requiring interventional treatment are indicated in brackets (according to the materials of the Children's Scientific and Practical Center for Heart Rhythm Disturbances based on the Moscow Research Institute of Pediatrics and Pediatric Surgery). a - radiofrequency catheter ablation; b - implantation of a pacemaker; c - implantation of a cardioverter-defibrillator.

Cardiac arrhythmias can develop at the height of infectious diseases, complicate diseases of other organs and body systems - CNS lesions, systemic diseases connective tissue, metabolic diseases, endocrine pathology. Heart rhythm disturbances often act as the main symptom of a number of hereditary diseases, such as primary electrical heart disease.

Among the factors influencing the degree of risk of cardiovascular complications in sports in children with heart rhythm disturbances, the specifics of arrhythmia and its possible pathophysiological consequences, as well as the general reaction of the cardiovascular system to stress (physical and psychological) caused by sports load, are distinguished. The risk is assessed separately for the training and competition regimen, taking into account the type, intensity, duration of the load and the influence of neurohumoral factors. In turn, the types of sports loads by the nature of their influence on cardiovascular system It is customary to divide into static and dynamic, and the intensity of the load is assessed at three levels: low, medium and high (Table 1). This classification was first proposed by J. Mitchell et al. , modified and approved research group in sports cardiology (The Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology), working group on the pathology of the myocardium and pericardium of the European Society of Cardiology (The Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology) and the American Academy of Pediatrics.

According to this classification, it is customary to distinguish sports associated with increased trauma and an increased risk of developing syncope. The division of sports into static and dynamic is conditional and reflects the predominant type of load. The predominance of dynamic or static loads is accompanied by different action on the cardiovascular system, which determines the prognosis for athletes

depending on the initial state. During dynamic loads, such as athletics (running), there is an active stretching of the muscles, accompanied by an increase in blood flow, an increase in myocardial oxygen demand. At the same time, heart rate, systolic and mean arterial pressure, cardiac output increase, and total peripheral resistance decreases. Over time, such changes lead to the expansion of the chambers of the heart, which is the main mechanism for adapting the heart to systematic loads of a dynamic nature. Static loads are characterized by a change muscle tone with isometric muscle contraction. A typical example is weightlifting. Changes in heart rate are minimal, there is an increase in both systolic and diastolic blood pressure. Stroke volume and total peripheral resistance do not increase. Thus, during prolonged static physical exertion, the adaptation of the heart is expressed in myocardial hypertrophy without an increase in the size of the heart cavities.

Methods of examination of a child with arrhythmia. Medical Commission of the International Olympic Committee, European Society of Cardiology and Federation international association Football approved a unified protocol for the screening of athletes, based on a 12-lead ECG, analysis of personal and family anamnestic data (emphasis on cases of sudden death, syncope and cardiac pathology) and physical examination. The situation becomes more complicated if a child has a heart rhythm disorder. The classic plan for a standard examination of a child with cardiac arrhythmias, in addition to taking an anamnesis, includes electrocardiography, Holter monitoring, echocardiography, and a stress test, which are performed at the primary outpatient stage of the examination. It is fundamentally important to differentiate cases of potentially life-threatening arrhythmias, as well as rhythm disturbances with already developed complications.

Table 1. Classification of sports according to the nature of their influence on the cardiovascular system (based on the classification of J. Mitchell et al., 1994)

Sports A. Low dynamic B. Medium dynamic C. High dynamic

I. Low Static Bowling, Cricket, Golf Table Tennis, Doubles Tennis, Volleyball, Baseball Badminton, Race Walking, Running (Marathon), Skiing, Squash

II. Auto Racing*, Equestrian*, Diving*, Motorcycling*, Gymnastics, Karate/Judo, Sailing Jumping, Figure Skating, Cross Country, Running (Sprint) Basketball, Biathlon, Ice Hockey, Rugby, Football, Middle and Long Distance Running , swimming, tennis, handball

III. High Static Bobsleigh*, Water Skiing*, Weightlifting, Shot Throwing*, Climbing*, Windsurfing* Bodybuilding, Wrestling, Downhill*, Snowboarding* Boxing, Canoeing, cycling*, decathlon, speed skating, triathlon*

Note. * - increased risk of syncope.

In the last decade, 24-hour Holter monitoring has become a routine method for studying patients with arrhythmias, the tasks of which include not only the detection of arrhythmia, the assessment of its severity, risk markers of life-threatening arrhythmias, but also the characterization of autonomic effects on the rhythm. The Revil long-term Holter monitoring system makes it possible to register any cardiac arrhythmias within a period of up to 3 years from the moment of its implantation under the patient's skin, to compare symptoms and detected cardiac arrhythmias, and to adopt the most appropriate strategy for managing a child.

Echocardiography allows you to confirm or refute the presence of an organic pathology of the heart (cardiomyopathy, congenital heart disease, etc.). An important result This research method is to assess the functional state of the myocardium and the contribution of arrhythmia to its violation (for example, to the development of diastolic dysfunction). Arrhythmias can be accompanied by remodeling of the heart with expansion of the cavities secondary to rhythm disturbance, the development of arrhythmogenic cardiomyopathy. Timely detection of these complications allows you to correctly navigate the tactics of managing the patient. Rhythm restoration in children without organic heart disease leads to the normalization of morphofunctional parameters, and echocardiography is the main method for monitoring their dynamics.

Stress tests (veloergometry, treadmill test) allow you to establish a relationship between rhythm disturbance and physical activity. It is especially important to identify the most dangerous exercise arrhythmias. Transesophageal electrophysiological examination is performed according to the indications for suspected paroxysmal tachycardia, sick sinus syndrome in patients with the Wolff-Parkinson-White phenomenon. An invasive electrophysiological study of the heart is performed in all children referred for interventional treatment of arrhythmia, and in some cases to clarify the nature of the arrhythmia, the degree of its danger to the patient and identify rhythm disturbances, for example, if it is impossible to establish the genesis of recurrent attacks of loss of consciousness using other research methods . A timely and correct diagnosis with the determination of the type of cardiac arrhythmias in the vast majority of cases allows you to completely cure the child or achieve a stable remission, and lost time can lead to serious complications and even sudden death with the same high probability.

A differentiated approach to solving the issue of competitive sports depending on the type of arrhythmia in children without organic heart disease. The decision on admission to competitive sports of children with various types arrhythmias

accepted on the basis of a standardized approach to the examination and assessment of identified symptoms.

In case of bradyarrhythmias (sinus bradycardia, sick sinus syndrome and atrioventricular blockades of II-III degree), the assessment of acceptable age-related values ​​of heart rate is fundamental in childhood. In connection with the pronounced age-related dynamics of the sinus rhythm frequency, it is recommended to focus on percentile tables to determine the boundaries of normal and pathological heart rate. A trend towards sinus bradycardia occurs when the heart rate falls below the 5th percentile. According to different authors, the level of permissible bradycardia in children aged 7-14 years with Holter monitoring is 32-42 per minute at night, and the duration of rhythm pauses should not exceed 1500-1880 ms.

Isolated sustained sinus bradycardia is quite rare in childhood. Most often, it serves as a manifestation of an increase in the influence of the parasympathetic division of the autonomic nervous system on the sinus node. Sinus bradycardia can be one of the manifestations of the sports heart, occurring in well-trained athletes. In childhood, we noted the strongest slowing effects on sinus rhythm in children involved in swimming, skiing and martial arts. Differential diagnosis is carried out between various pathophysiological mechanisms for the development of sinus bradycardia. It is important to establish the degree of dysfunction of the sinus and / or atrioventricular nodes. Unfavorable prognostic signs in children with bradyarrhythmias are attacks of loss of consciousness, a progressive decrease in the average daytime, maximum and minimum daytime and nighttime heart rate indicators according to Holter monitoring, an increase in the number and duration of rhythm pauses, the appearance of additional rhythm and conduction disturbances, an inadequate increase in the frequency of sinus rhythm during a test with a dosed physical load, aggravation or provocation of additional rhythm disturbances on the samples.

Familial cases are unfavorable prognostic. Sudden cardiac death in families of direct relatives at a young age (up to 40 years) is considered as an unfavorable prognostic factor. The frequency of occurrence of sinus bradyarrhythmias and atrioventricular blockades I-II degree, among athletes is quite high. In the absence of symptoms and signs of organic heart disease, as well as with the restoration of normal conduction

during exercise, as a rule, the prognosis is favorable. Contraindications for playing sports in children with various types of bradyarrhythmias depend on the degree of dysfunction of the sinus and atrioventricular nodes, the presence of symptoms, and the nature of rhythm adaptation to exercise (Table 2).

Patients with structural changes hearts, as well as in the absence of such, but having an implantable antiarrhythmic device (pacemaker), can only be admitted to sports with minimum requirements to the adaptation of the heart rate (!L, V; see Table 1). At the same time, Holter monitoring and stress test data should confirm the satisfactory adaptation of the imposed rhythm to physical activity. The possibility of playing sports is discussed no earlier than 6 months after implantation, in the absence of signs of myocardial dysfunction. contact sports

should be excluded. Protective measures have been developed chest to minimize the risk of damage to implanted antiarrhythmic devices in athletes.

When deciding on admission to competitive sports for children with supraventricular tachyarrhythmias, it is necessary to determine whether they are the result of an organic heart lesion. It has now been shown that in 95% of cases, supraventricular tachyarrhythmias are found in children with structurally normal hearts. Of decisive importance is the presence of clinical symptoms, as well as the need for the patient to take antiarrhythmic drugs, which excludes the possibility of playing sports. Since this type of arrhythmia does not belong to potentially dangerous arrhythmias, in the absence of clinical manifestations, access to sports in children should not be limited (Table 3).

Table 2. Differentiated approach to addressing the issue of practicing competitive sports in children with bradyarrhythmias

Symptomatic sinus bradycardia (<5%о) и/или паузы ритма >2 s, SSSU Study of anamnesis, ECG, stress test, HM, echocardiography a) symptoms +; b) symptoms - (3 months), adequate increase in heart rate during exercise a) temporary cessation of sports activities; b) all sports are allowed once a year

AV block I and Mobitz I History study, ECG, stress test, HM, echocardiography Symptoms -, restoration of atrioventricular conduction during exercise All sports are allowed 1 time per year

Mobitz II (AV-block-yes III) History study, ECG, stress test, HM, echocardiography Symptoms -, VA -, heart rate > 2% Sports allowed! A, B; AI, B (see Table 1) 2 times a year

a) Rigid bradycardia, AV block I-II; b) AV block III Study history, ECG, stress test, HM, echocardiography Symptoms +, VA +, heart rate< 2%, паузы >2.5 s, myocardial dysfunction a, b) sport is not recommended Observation by a cardiologist

Note. Here and in Table. 3-5: + present; - absent; ECG - electrocardiography; echocardiography - echocardiography; HM - Holter monitoring; AB - atrioventricular; SSS - sick sinus syndrome; VA - ventricular arrhythmia.

Table 3. Differentiated approach to addressing the issue of competitive sports visas in children with supraventricular tachyarrhythmias

Extrasystole Study of history, ECG, thyroid function Symptoms - All sports are allowed -

Non-paroxysmal and paroxysmal History, ECG, echocardiography, EFI RFA +: after 3 months in the absence of relapses All sports are allowed once a year

SITA RFA is not indicated -, SITA is not stressful, echocardiography is normal All types, except for those selected * (see Table 1) 1 time per year

Atrial flutter/fibrillation History study, ECG, stress test, HM, echocardiography, EFI RFA +; no SSSU, sinus rhythm >3 months; no Wolff-Parkinson-White syndrome, not receiving therapy Individual decision: !A (see Table 1) 2 times a year

Note. Here and in Table. 4 and 5: SVTA - supraventricular tachyarrhythmia; EFI - electrophysiological study; RFA - radiofrequency ablation.

In determining indications for other types of supraventricular tachyarrhythmias, efficiency matters medical measures. In recent years, interventional methods have become widespread in pediatric practice - radiofrequency catheter ablation and cryoablation. In cases where radiofrequency ablation is effective, 3 months after the procedure, in the absence of relapses, the child can be allowed to practice any sports. The recommended frequency of observation is once a year (see Table 3).

Atrial flutter is a rare species rhythm disturbances in children and adolescents and can develop in the postoperative period in patients operated on for congenital heart defects, or against the background of the sick sinus syndrome in the child. In cases of successful radiofrequency ablation 3 months after interventional treatment, the question of the possibility of playing sports can also be resolved positively in relation to sports belonging to category 1A. In cases where a stable sinus rhythm has been established (with a follow-up period of more than 3 months), there are no signs of preexcitation on the ECG, there are no clinical manifestations and indications for therapy, it is possible to expand recommendations for sports.

Ventricular arrhythmias are much less common in childhood than supraventricular arrhythmias, and are significantly more often associated with the development of life-threatening complications, including sudden cardiac death. These arrhythmias may occur in children with anatomically normal hearts, as a consequence of primary electrical heart diseases such as long QT syndrome, Brugada syndrome (treated separately); may develop against the background of organic lesions

heart: myocarditis, cardiomyopathy, heart tumors, arrhythmogenic dysplasia of the ventricular myocardium; occur after surgical interventions in children with congenital heart defects (incisional arrhythmias, arrhythmias due to increased pressure in the ventricles of the heart). Ischemic ventricular tachyarrhythmias are rare in childhood and usually occur in children with hypertrophic cardiomyopathy, congenital anomalies of the coronary arteries, and Kawasaki disease.

The issue of admission to competitive sports in children with ventricular arrhythmias that developed in the absence of organic heart disease depends on the type of arrhythmia (Table 4). The decision, as with other cardiac arrhythmias, should be preceded by a full clinical examination according to the plan presented above. Ventricular extrasystole does not impose any restrictions in cases where it is relatively rare, monomorphic, is not accompanied by symptoms, signs of myocardial dysfunction, and there are no indications in the family of syncope or cases of sudden unexplained death in young people (see Table 4). Such children can, being under the supervision of a specialist at least once a year, go in for sports. During the annual examination, including Holter monitoring, ECG in various functional states and ultrasound examination of the heart, risk factors for this type of arrhythmia are monitored. The morphology of arrhythmia, its prevalence per day, the state of central hemodynamics are assessed.

In cases where there are indications for radiofrequency ablation of the arrhythmogenic focus, there are no contraindications for practicing any sports 3 months after interventional treatment in the absence of symptoms and recurrence of arrhythmia. With symptomatic ventricular

Table 4. Differentiated approach to addressing the issue of practicing competitive sports with ventricular arrhythmias

Ventricular extrasystole Study of history, ECG, stress test, HM, echocardiography Symptoms -, sudden death in the family -, relationship with exercise -, monomorphic,<15 тыс./24 ч, эхоКГ - норма Разрешены все виды спорта 1 раз в год

RFA + After 3 months all sports are allowed once a year

RFA -, symptoms -, myocardial dysfunction, polymorphism 1A sports are allowed (see Table 1) 1 time per year

Non-paroxysmal ventricular tachycardia History study, ECG, stress test, HM, echocardiography, EFI* RFA + All sports are allowed 2 times a year

RFA -, symptoms +, connection with exercise Sport not recommended 2 times a year

Paroxysmal Study of anam- RFA + All types are allowed 2 times a year

ventricular neza, ECG, echocardiography, sports

tachycardia HM, EFI

Note. * - according to indications.

howling extrasystole, including those accompanied by signs of myocardial dysfunction, when radiofrequency ablation cannot be performed, for example, due to the location of the ectopic focus in close proximity to the structures of the normal conduction system of the heart or epicardially, the child may, at the discretion of the specialist, be admitted only to sports class 1A loads (see Table 1). With non-paroxysmal ventricular tachycardia, the decision on the possibility of practicing competitive sports is made taking into account the same principles and directly depends on the possibility of eliminating arrhythmia by interventional methods. Frequency of monitoring at least 1 time in 6 months. With paroxysmal ventricular tachycardia, children can be allowed to play sports only if the arrhythmia is effectively cured and not receiving antiarrhythmic drugs. Examination is recommended at least once every 6 months.

Primary electrical heart disease. In some cases, the cause of sudden death remains unclear, despite a detailed pathomorphological examination. The assumption that a significant proportion of these cases are also the result of fatal cardiac arrhythmias caused by primary electrical disturbances in the myocardium is increasingly being confirmed. Progress in molecular genetics and cellular electrophysiology has made it possible to unravel the mechanisms essential to understanding the causes of sudden arrhythmic death. Currently, a number of pathological conditions have been identified with a high risk of sudden death due to life-threatening ventricular arrhythmias that develop in individuals with anatomically normal hearts. They are grouped under "primary electrical heart diseases" and include congenital cardiac canalopathies. This constantly expanding group of pathological conditions currently includes congenital long QT syndromes, catecholaminergic ventricular tachycardia, Brugada syndrome, short QT syndrome, and "idiopathic" ventricular fibrillation. According to M. Askegshap, this group also includes congenital sick sinus syndrome, progressive damage to the conduction system of the heart, familial atrial fibrillation, and from 5 to 10% of all cases of sudden cardiac death syndrome in infants. Each of these cardiac canalopathy is caused by a specific mutation in the genes encoding the structure of cardiac ion channel proteins responsible for the transmembrane transport of ions that regulate the intracellular electrical charge of cardiomyocytes.

The frequency of occurrence of certain primary electrical heart diseases has now been established, which should serve as a guide.

for the completeness of their detection in the population at the primary level. Thus, long QT syndrome in the population occurs with a frequency of about 1:2000. Gender and age have a modulating effect on the clinical manifestation and the likelihood of sudden cardiac death in patients.

The basis for the timely diagnosis of these conditions is ECG screening, which should optimally be performed before the age of 3 years (detection of pathological ECG phenomena). In addition, an ECG examination of families from risk groups and an in-depth examination of patients with repeated syncope are of great diagnostic value. It is recommended that all direct relatives of 1-11 degree relatives of probands with primary electrical heart diseases be examined and stress tests should be performed if the patient has a history of complaints associated with physical activity - dizziness, syncope or palpitations. Implantation of a cardioverter-defibrillator is indicated in patients with a high risk of sudden death (history of clinical death or repeated syncope during antiarrhythmic therapy).

At present, when the objective data of screening studies indicate a fairly high incidence of primary electrical heart disease in the population, the need for development in the field of social rehabilitation of patients with these types of pathology is becoming more and more obvious. An active lifestyle is of no small importance. It is necessary for each individual patient to determine the acceptable level of physical activity. Unfortunately, in a large percentage of cases with these diseases, the load is a provoking factor for the development of life-threatening conditions. For example, the first molecular genetic variant of long QT syndrome and catecholaminergic ventricular tachycardia are associated with an increased risk of sudden cardiac death during physical stress. However, a differentiated approach based on an in-depth clinical, electrophysiological and genetic examination, stratification of risk factors for syncope and sudden cardiac death allows us to identify subgroups of patients who do not have a risk of sudden death when practicing certain sports (Table 5).

All sports are clearly contraindicated in patients with a history of cardiac arrest or syncope. According to international recommendations, category 1A light sports are not contraindicated in asymptomatic (including against the background of severe physical activity) patients with long QT syndrome who do not have cases of sudden death in the family; with QTc interval at rest<480 мс. По мнению меж-

According to an international expert group, patients with a genetically confirmed but phenotypically negative long QT syndrome, when the mutation corresponding to the syndrome is detected in asymptomatic individuals with a normal QT interval on the ECG, can be admitted to competitive sports, excluding swimming. Swimming is a known trigger of life-threatening arrhythmias in patients with the most common first molecular genetic variant of the syndrome (LQT1) in the population. Patients with long QT syndrome and implanted antiarrhythmic devices should only be allowed to participate in sports with low levels of both dynamic and static stress, and the risk of injury (contact sports) should be avoided, as trauma may disrupt the operation of the implanted device. The frequency of observation in this group is at least 1 time in 6 months.

Phenotypic manifestations of short QT syndrome (QTc<300 мс) в настоящее время изучены недостаточно, вследствие чего в этой группе можно обсуждать только класс спортивных нагрузок!А. Эти виды спорта могут рассматриваться только в отсутствие в анамнезе симптомов (синкопе и пред-синкопе, сердцебиения), нарушений ритма (при всех возможных способах регистрации), случаев внезапной смерти в семье. Больным с катехоламинерги-ческой желудочковой тахикардией занятия спортом категорически противопоказаны, в том числе пациентам с имплантированными кардиовертерами-де-фибрилляторами. Пациентам с синдромом Бругада в настоящее время рекомендуется ограничение в занятиях всеми видами спорта, кроме!А, несмотря на то что очевидной связи между нагрузкой и внезапной

All athletes with cardiac arrhythmias should undergo a periodic examination 1-2 times a year. It is recommended to carry out an examination immediately after training, which will determine the possible impact of sports loads on the development and maintenance of cardiac arrhythmias. Sports activities are not recommended at the time of treatment with antiarrhythmic drugs. In this regard, in recent years, indications for interventional methods of treatment of adolescents who express an active desire to engage in competitive sports, but have some kind of rhythm or conduction disturbance that require control with antiarrhythmic drugs, have been expanding. The same applies to patients with non-life-threatening cardiac arrhythmias with an increase in arrhythmias during a stress test in the absence of absolute indications for the appointment of antiarrhythmic drugs or radiofrequency ablation, but who have a pronounced motivation for sports. The determining moment for deciding on the possibility of interventional treatment, in addition to the desire of the patient in such cases, is the sufficient frequency of occurrence of arrhythmias (at least 15,000 extrasystoles per day; persistent Wolff-Parkinson-on-White ECG phenomenon). After radiofrequency ablation, the child can play (continue) sports after 3 months.

Thus, from the point of view of sports medicine, the clarification of the nature of the arrhythmia, the exclusion of an organic lesion of the cardiovascular system and the assessment of the risk of developing life-threatening arrhythmias are of primary importance in determining the possibility of admission to sports. Conclusion

Table 5. Differentiated approach to addressing the issue of engaging in competitive sports in patients with primary electrical heart disease

Long interval syndrome History study, ECG, stress test, HM, echocardiography, Symptoms -, sudden death in the family -, relationship with exercise -, Ob:<480 мс; генетический вариант LQT3 исключен ]А (кроме варианта LQT3) 2 раза в год

EPS*, ICD*, genetic studies Genetic data +, phenotype -, history of syncope - All species except swimming 2 times a year

History of syncope or sudden death in the family; genetic data + and association of presyncope with exercise, variant LQ73 Sport excluded 2 times a year

Short interval syndrome 0-^ History study, ECG, Symptoms -, arrhythmias -, sudden death in the family - ON? 2 times per year

Brugada syndrome stress test, HM, echocardiography, EFI* Symptoms +, genetics +, arrhythmias +, sudden death in the family + Sport excluded

Catecholaminergic ventricular tachycardia Regardless of the clinic and examination data Sport excluded

Note. * - according to indications; ICD - implanted cardioverter defibrillator. RUSSIAN BULLETIN OF PERINATOLOGY AND PEDIATRIES, 1, 2010

about the possibility of playing sports for children with heart rhythm disorders is taken on the basis of an examination that solves the following tasks:

1. Clarification of the clinical and electrophysiological variant of rhythm disturbance in accordance with the generally accepted classification, exclusion of life-threatening arrhythmias, primary electrical heart disease.

2. Exclusion of organic pathology of the heart and the possible connection of arrhythmia with a previous infectious disease.

3. Determination of the sensitivity of arrhythmia to various functional states, with special attention to the reaction of rhythm disturbance to physical activity.

4. Determination of risk factors for the development of life-threatening conditions, including possible adverse hemodynamic consequences and the risk of fatal arrhythmias. The development of clinical electrophysiology of the heart and the accumulation of experience in the management and observation of children with various, including rare, cardiac arrhythmias will constantly make adjustments to the standards of examination and monitoring, contraindications to sports. The determining factor in this matter is the further improvement of methods for the radical correction of rhythm disturbances, further research in the field of drug support, the study of the prognosis and chronic forms of rhythm disturbances.

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MARIA ALEKSANDROVNA GRADUATED THE PEDIATRIC FACULTY OF THE II MOSCOW MEDICAL INSTITUTE NAMED AFTER N.I. N.I. PIROGOV (CURRENTLY, State Budgetary Educational Institution of Higher Professional Education N.I. PIROGOV RNIMU of the Ministry of Health of the Russian Federation).

In 1987 she defended her Ph.D. thesis on the topic “Characteristics of clinical and pathogenetic variants of chronic non-paroxysmal tachycardia in children and approaches to rational therapy” (headed by Prof. N.A. Belokon) in the specialty “Pediatrics”. In 1993 she defended her doctoral dissertation on the topic “Predicting the risk of developing life-threatening conditions and sudden death in children with cardiac arrhythmias, the principles of prevention” (consultant academician Yu.E. Veltishchev). Since 1987, she has been continuously working at the Institute, having gone from researcher to chief researcher, head of the Federal Children's Center for Rhythm Disturbances, and director of this Institute. He is the President of one of the largest specialized professional medical associations in Russia - the All-Russian Public Organization "Association of Pediatric Cardiologists of Russia", which unites more than 2,000 pediatric cardiologists from all regions of the Russian Federation.

Under the leadership of M.A. Shkolnikova in Russia introduced molecular genetic studies of children with life-threatening arrhythmias and their families, which made it possible to establish genetic variants of a hereditary pathology associated with a high risk of sudden death. She developed and implemented effective methods of therapeutic treatment and prevention of life-threatening tachyarrhythmias and bradyarrhythmias in children and young people, long QT syndrome, and prevention of sudden infant death syndrome. Indications for cardiac surgical correction of arrhythmias in children, risk criteria for cardiogenic attacks of loss of consciousness and sudden cardiac death have been developed; a system for monitoring risk factors for sudden cardiac death in children with cardiac arrhythmias has been developed; an algorithm for family examination and observation in cases of hereditary forms of life-threatening arrhythmias has been developed and implemented. The introduction of these methods of diagnostics and treatment made it possible to achieve the recovery of 93% of children with tachyarrhythmias and reduce the mortality of children with life-threatening arrhythmias by 10 times.

Maria Alexandrovna Shkolnikova for many years has been the organizer and coordinator of the development of one of the fastest growing and high-tech areas of pediatrics - pediatric cardiology. For more than 15 years M.A. Shkolnikova was the chief pediatric cardiologist of the Ministry of Health of the Russian Federation. With her direct participation, "children's cardiology" in Russia became one of the independent specialties requiring in-depth training, which made it possible to focus the attention of specialists on the need to master and widely implement a large amount of special knowledge and skills, in accordance with today's high requirements for specialists in this field.

M.A. Shkolnikova - chief expert - pediatric cardiologist of the Moscow Department of Health, laureate of the Lenin Komsomol Prize for Medicine, laureate of the Moscow Mayor's Prize for the developed methods for diagnosing and preventing sudden cardiac death in children. He is the author of a number of inventions and patents. Under the leadership of M.A. Shkolnikova defended 17 candidate and 3 doctoral dissertations. She is the author of more than 300 publications (including more than 100 published in foreign press), 11 monographs and 39 chapters in monographs, 33 methodological recommendations of the Ministry of Health of the Russian Federation and the Moscow Department of Health. She gives more than 20 lectures annually and conducts practical classes and seminars with medical residents and pediatricians on the examination and treatment of patients with cardiac pathology. He actively works with young employees, educating a school of young specialists in Russia, continuing the work of Professor N.A. Belokon Among her students are talented doctors, heads of clinics, heads of pediatric departments, chief specialists - pediatric cardiologists in various regions of Russia, well-known scientists, healthcare organizers. Many of them have won recognition not only in our country, but also abroad, annually receiving prestigious professional awards at all-Russian and international congresses.

M.A. Shkolnikova is the organizer of 8 All-Russian Congresses "Pediatric Cardiology", she is the national representative of Russia in the European Association of Pediatric Cardiologists, a board member of the Russian Arrhythmological Society, a member of the European Society of Arrhythmologists of the European Association of Cardiology and a number of other public organizations. Currently he is a member of the editorial boards of 3 pediatric and 2 cardiology journals.

Editorial Board of the journal "Practice of a Pediatrician"
and editorial board congratulations
Maria Alexandrovna Shkolnikova, Professor, President of the All-Russian Public Organization "Association of Pediatric Cardiologists of Russia"
with the assumption of the position of Director of the Leading Federal Pediatric Center of Russia
– Research Clinical Institute of Pediatrics, State Budgetary Educational Institution of Higher Professional Education “RNIMU named after N.I. N.I. Pirogov" of the Ministry of Health of Russia.

On July 8-9, we talked with the doctor of medical sciences, professor, president of the Association of Pediatric Cardiologists of Russia Shkolnikova Maria Alexandrovna .

- On July 8-9, a congress on pediatric cardiology will be held. What are the main trends in this direction?

— Russia is a country with one of the highest mortality rates from cardiovascular diseases among developed countries. Therefore, the effective introduction of new technologies in the diagnosis and treatment of cardiovascular diseases from an early age is of strategic importance.

It should be noted that over the past decades, the mortality of children from all diseases has been constantly decreasing. However, mortality from cardiovascular diseases began to decrease only in the 2000s - after the widespread introduction of high-tech types of medical care, an increase in the number of heart surgeries in children with congenital heart defects and arrhythmias.

In recent years, there has been significant progress in, which is due to the intensive development of cardiovascular surgery, including surgery of increased complexity. Invasive and non-invasive cardiac electrophysiology, minimally invasive surgery, monitoring of risk groups, prenatal diagnosis and other areas of scientific and practical research and the introduction of new treatment technologies have served as the basis for improving the diagnosis and treatment outcomes in children with heart disease in our country and abroad.

What do you expect from Congress? What are the goals?

- First of all, this is an exchange of experience, drawing attention to new technologies, comparing the level of regional health care in the field of medical care for children with heart disease. Also, discussion of problems and consolidation of the medical community for their prompt and optimal solution.

What are the disease statistics? What is being treated better now?

- In Russia, out of 27 million children, 1 million 65 thousand have cardiovascular diseases, and 50% of them are chronic forms.

According to the data of the chief children's cardiologists of the regions, the first place among cardiovascular diseases is occupied by congenital heart defects (25%), the second place is occupied by cardiac arrhythmias (up to 20%), arterial hypertension is in the fourth place (12%) (this is consistent with the data official statistics), the proportion of cardiomyopathies and carditis is 4%, and rheumatic diseases also account for 4%.

— Are medical technologies sufficiently developed today?

— New surgical, interventional, cardiological technologies play an important role in reducing mortality from diseases of the circulatory system among both children and adults.

We, specialists, together with the health authorities, have taken up the problem of cardiovascular diseases in childhood very seriously in recent years. Diagnostic methods have been introduced, they have become available for the primary link in the provision of medical care to the child population, and this has made it possible to increase the detection rate by almost 5 times compared to the 1990s. This indicates the high quality of diagnostic technologies and, accordingly, the best treatment outcomes.

Modern echocardiography makes it possible to assess global and regional contractility and many other parameters of the anatomy and functional state of the cardiovascular system. We have made great strides in this area, and the results of an expert echocardiographic study using the latest generation of equipment can be compared with MRI. ECG Holter monitoring has become a routine study everywhere. A tilt test has been introduced to diagnose the causes of loss of consciousness, invasive electrophysiological studies of the heart, and much more.

— Do doctors know how to use the new equipment today? It happens that they brought equipment, but there is no one to work or they do not know how. How is the process going?

— Specialists are interested in their competence and now pediatric cardiologists must master the basic examination methods - ECG, Holter, ECHO-cardiography. So far, this has not yet become the norm, but in the near future, thanks to the introduction of new requirements for specialists, this will become a necessary condition for the work of a pediatric cardiologist.

- Medicine is based on specialists who want to develop, read literature. How are things going in this regard in pediatric cardiology? Are there specialists?

- There are not enough specialists - they are trained in residency, but these places are not enough, and the scholarships are so small that it is impossible for a young doctor to live on them. So it turns out that at a time when there is a question of choosing a specialty, not everyone will decide to live a difficult life for another two years without the opportunity to start a family, etc. Scholarships are needed for those who have decided to devote themselves to hard work and are motivated to work and study difficult questions diagnosis and treatment of heart disease in children.

Interest in the specialty is very high. It is necessary to support him, and everything will be fine with the specialists.

When should parents show their child to a pediatric cardiologist?

- There is a basic rule - to show a specialist when there is anxiety in connection with the symptoms or unusual behavior of the child. For heart disease, these are fainting, palpitations, unexpected fatigue and overwork during normal exercise. Also, cases of sudden death in relatives at a young age are a reason to examine the child, and other family members. In addition, it is necessary to show up before the child goes in for big sports, if there is such a desire. Also, the child should be shown to a cardiologist before surgery.

- Your advice to parents.

- Parents should be given advice at the appointment with a specialist. Here I can limit myself - set a good example for children. Don't smoke, don't overeat, and exercise - remember, exercise is better than sports. It is needed daily.

Often parents panic. How to deal with this condition? Is this the doctor's job?

- This is the main task of the media. They should be explained and helped to understand new treatments, as well as highlight new technologies and general rules of conduct when detecting diseases.

- A lot of controversy around the VSD. Is there such a diagnosis? How to treat?

— There is such a state. We, cardiologists, diagnose it using methods for assessing the autonomic regulation of the cardiovascular system. Professor N. A. Belokon, who was our teacher, together with the school of A. M. Vein, developed diagnostic criteria and methods for treating autonomic regulation disorders in children. This is relevant even now. Violation of autonomic functions can become the basis for the formation of more persistent dysfunctions of other organs and systems, therefore, it is better to identify and control using simple methods from childhood.

In adulthood, manifestations of autonomic dysfunction are mainly considered within the framework of psychosomatic diseases.

- Where to be treated - at home or abroad?

- As an example, I can cite the Center for Heart Rhythm Disturbances in Children, which was organized 20 years ago on the basis of our institute (now NIKI of Pediatrics named after Yu. E. Veltishchev). During this time, the service covered all of Russia, and not a single child was sent abroad for treatment. The treatment results are excellent, even according to foreign colleagues. This means that other issues can be solved in this way. You just need to systematically approach their solution. Surgery for congenital heart defects is also developing and not only in Moscow, but also in a number of territories - Tomsk, Samara, Novosibirsk, Astrakhan, St. Petersburg, Kazan - treatment at the level of the best world experience.

- Andrey Petrovich Prodeus once said in an interview that the best immunomodulating agents are the right way of life and love in the family. What do you think is the most important for the harmonious development and growth of the child and the absence of diseases in the baby?

- You need to love the baby, pay attention to physical culture, proper nutrition, the regime - walks. You should also undergo a medical examination in a timely manner, consult a doctor with symptoms, and not wait for them to pass on their own. A harmonious combination of home and professional surveillance is needed.

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