Dr My Leg/Legs Are Dr My Leg/Legs Are Swollen…Swollen…

Dr Dr Rashmi Gaekwad Rashmi Gaekwad

RDH RDH 2020thth April 2011 April 2011

Foot, leg and Ankle swelling--Causes

Heart FailureLiver FailureRenal Failure

DVT, CVI, Varicose Veins, Surgery, LymphoedemaStarvation, Malnutrition, Insect Bite/Sting, Burns

Obstruction

Hormones-oestrogen (OCP,HRT)/TestosteroneCalcium Channel Blockers- Nifedipine, amlodipine, Diltiazem, Felodipine,

Steroids, NSAIDsAntidepressants- MAO Inhibitors, Tricyclics (Amitry, Nortr, Desipramine)

How are you going to How are you going to explain it to your patients?explain it to your patients?

The Heart Pumps blood through the arteries The Heart Pumps blood through the arteries under high pressure.under high pressure.

This pressure is lost and blood relies in simple This pressure is lost and blood relies in simple back pressure to move to the heart.\This ia back pressure to move to the heart.\This ia aided by muscle activity, squeezes the veins aided by muscle activity, squeezes the veins and pushes blood along.and pushes blood along.

When muscle movement is lost, it is harder to When muscle movement is lost, it is harder to get the blood back up from the legs.get the blood back up from the legs.

Water Seeps from distended veins into Water Seeps from distended veins into surrounding tissues and legs and feet swell.surrounding tissues and legs and feet swell.

Repeated episodes of swelling , veins become Repeated episodes of swelling , veins become more leaky.more leaky.

One way valves in the veins are collapsing One way valves in the veins are collapsing under the weight of all the blood, pooled on under the weight of all the blood, pooled on top of themtop of them

The swelling gets worseThe swelling gets worse Complications:Complications: Needles and pins sensation-poor Needles and pins sensation-poor

microcirculationmicrocirculation Lousy circulation causes blood to clotLousy circulation causes blood to clot Clot can impede circulationClot can impede circulation Break loose-travel to the Brain-Stroke, Lungs- Break loose-travel to the Brain-Stroke, Lungs-

Pulmonary Embolus,Pulmonary Embolus,

Heart FailureHeart Failure

Causes:Causes: High Output-Hyperthyroidism, Anaemia, AV MalHigh Output-Hyperthyroidism, Anaemia, AV Mal Low Output-Preload, Pump Failure, After loadLow Output-Preload, Pump Failure, After load RHF-PHTN,TRRHF-PHTN,TR

BACKGROUNDBACKGROUND Complex syndrome caused by impaired cardiac functionComplex syndrome caused by impaired cardiac function Two types: left ventricular systolic dysfunction (LVSD) and heart Two types: left ventricular systolic dysfunction (LVSD) and heart

failure with preserved ejection fraction (HFPEF) failure with preserved ejection fraction (HFPEF) Most common cause: coronary artery diseaseMost common cause: coronary artery disease 30–40% of patients die within a year of diagnosis30–40% of patients die within a year of diagnosis

Prevalence Prevalence Around 900,000 people in the UK, average age-76yrsAround 900,000 people in the UK, average age-76yrs expected to rise in the futureexpected to rise in the future GP HF register-average 10 pts new diagnosis, 30pts per GPGP HF register-average 10 pts new diagnosis, 30pts per GP

Symptoms/SignsSymptoms/Signs

LVF-SOB,NOCTURAL COUGH/WHEEZE, LETHARGY/FATIGUE, LVF-SOB,NOCTURAL COUGH/WHEEZE, LETHARGY/FATIGUE, <EXERCISE TOLERANCE<EXERCISE TOLERANCE

RVF-OEDEMA, NAUSEA/ANOREXIA,FATIGUE/WASTING, ABDO RVF-OEDEMA, NAUSEA/ANOREXIA,FATIGUE/WASTING, ABDO DISCOMFORTDISCOMFORT

SIGNSSIGNS-TACHYOPNEA,TACHYCARDIA, MUSCLE WASTING, -TACHYOPNEA,TACHYCARDIA, MUSCLE WASTING, >JVP,HEPATOMEGALY, ASCITES.BASAL- CREPITATIONS, EFFUSIONS, >JVP,HEPATOMEGALY, ASCITES.BASAL- CREPITATIONS, EFFUSIONS, WHEEZE.CARDIOMEGALY, PULSUS ALTERNANS.WHEEZE.CARDIOMEGALY, PULSUS ALTERNANS.

DiagnosisDiagnosisIn patients with symptoms and signs of heart failure:In patients with symptoms and signs of heart failure:

Measure serum natriuretic peptides in patients without previous Measure serum natriuretic peptides in patients without previous MIMI

Refer to have transthoracic Doppler 2D echocardiographyRefer to have transthoracic Doppler 2D echocardiographyand specialist assessment within 2 weeks ifand specialist assessment within 2 weeks if

previous MIprevious MI

BNP > 400 pg/ml orBNP > 400 pg/ml orNTproBNP > 2000 pg/mlNTproBNP > 2000 pg/ml

Refer to have transthoracic Doppler 2D echocardiography and Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks if:specialist assessment within 6 weeks if:

BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/mlBNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is

unlikely in an untreated patientunlikely in an untreated patient BNP-Raised in LVH, PE, Renal Dysfunction, Sepsis, COPD, >70yrs, BNP-Raised in LVH, PE, Renal Dysfunction, Sepsis, COPD, >70yrs,

Cirrhosis, DMCirrhosis, DM

When to refer to the When to refer to the specialist MDTspecialist MDT

for the initial diagnosis of heart failurefor the initial diagnosis of heart failure

for the management of severe heart failure (NYHA class IV)for the management of severe heart failure (NYHA class IV)

heart failure that does not respond to treatment heart failure that does not respond to treatment

heart failure that can no longer be managed at homeheart failure that can no longer be managed at home

when they are planning a pregnancy or are pregnantwhen they are planning a pregnancy or are pregnant

when they have heart failure due to valve diseasewhen they have heart failure due to valve disease

Co-morbidities that may impact on HF(COPD, RF, PVD,Gout,Anaemia)Co-morbidities that may impact on HF(COPD, RF, PVD,Gout,Anaemia)

Angina, AF, Symptomatic ArrhythmiasAngina, AF, Symptomatic Arrhythmias

Mgmt-non drug Mgmt-non drug measuresmeasures

Patient -educate, Rx, prognosis, written plan-Self-care confidence, Patient -educate, Rx, prognosis, written plan-Self-care confidence, maintenance & managementmaintenance & management

Diet-low salt adequate calories, restrict alcohol, loose weight if obeseDiet-low salt adequate calories, restrict alcohol, loose weight if obese Restrict fluid intake in severe HFRestrict fluid intake in severe HF Lifestyle measures: Smoking cessation, regular exerciseLifestyle measures: Smoking cessation, regular exercise Vaccination: Influenza (yrly) and Pneumococcal (once)Vaccination: Influenza (yrly) and Pneumococcal (once) Air Travel-depend on their clinical conditionAir Travel-depend on their clinical condition Assess for depressionAssess for depression

Mgmt-pharmacologicalMgmt-pharmacologicalOffer both ACE inhibitors and beta-blockers licensedOffer both ACE inhibitors and beta-blockers licensed

for heart failure to all patients with LVSDfor heart failure to all patients with LVSD

Offer beta-blockers licensed for heart failure to Offer beta-blockers licensed for heart failure to allallpatients with LVSD, including older adults and pts withpatients with LVSD, including older adults and pts with

peripheral vascular diseaseperipheral vascular disease erectile dysfunctionerectile dysfunction diabetes mellitusdiabetes mellitus interstitial pulmonary disease interstitial pulmonary disease COPD without reversibilityCOPD without reversibility

Seek specialist advice and consider adding one of the following if patient remains symptomatic Seek specialist advice and consider adding one of the following if patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker: despite optimal therapy with an ACE inhibitor and a beta-blocker:

aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month)month)

ARB licensed for heart failure (especially in NYHAARB licensed for heart failure (especially in NYHAlclass II-III)lclass II-III)

hydralazine in combination with nitrate (especially in people of African or Caribbean origin hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHAwith NYHAclass III-IV) class III-IV)

Digoxin-AF+HFDigoxin-AF+HF

Anticoagulation-Thromboembolism, LV aneurysmAnticoagulation-Thromboembolism, LV aneurysm

Aspirin-Atherosclerotic arterial disease (CHD)Aspirin-Atherosclerotic arterial disease (CHD)

Statins, Amiodarone, Spironolactone,Statins, Amiodarone, Spironolactone,

Monitoring/RehabMonitoring/RehabAll patients with chronic heart failure require All patients with chronic heart failure require

monitoring. This monitoring should include:monitoring. This monitoring should include: a clinical assessment of functional capacity, fluid a clinical assessment of functional capacity, fluid

status, cardiac rhythm (minimum of examining status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional statusthe pulse), cognitive status and nutritional status

a review of medication, including need for a review of medication, including need for changes and possible side effectschanges and possible side effects

serum urea, electrolytes, creatinine and eGFRserum urea, electrolytes, creatinine and eGFR

When a patient is admitted to hospital because of When a patient is admitted to hospital because of heart failure, seek advice on their management heart failure, seek advice on their management plan from a specialist in heart failureplan from a specialist in heart failure

Offer a supervised group exercise-based Offer a supervised group exercise-based rehabilitation programme designed for patients rehabilitation programme designed for patients with heart failurewith heart failure

Case 1Case 1 86 year old Mr DF presented to his GP with cough/sputum, SOB, swelling 86 year old Mr DF presented to his GP with cough/sputum, SOB, swelling

of his legs, unable to sleep well at night for 2 weeks. He had a h/o fall and of his legs, unable to sleep well at night for 2 weeks. He had a h/o fall and has been c/o chest pain, right shoulder pain.has been c/o chest pain, right shoulder pain.

BG-had THR ®, Lives with his wife, quite independent., never smokedBG-had THR ®, Lives with his wife, quite independent., never smoked Meds-Lactulose, Simvastin, omeprazole, Aspirin.Meds-Lactulose, Simvastin, omeprazole, Aspirin. O/E- temp of 37.4,sats-94% bi-basal crackles, pedal oedemaO/E- temp of 37.4,sats-94% bi-basal crackles, pedal oedema How would you manage this patient?How would you manage this patient?

Case 2Case 2 Home visit –Mrs MF 68 yrs old -swelling of legs, decreased Home visit –Mrs MF 68 yrs old -swelling of legs, decreased

mobility and sore creases for 3 weeks. Poor sleep. Not taking her mobility and sore creases for 3 weeks. Poor sleep. Not taking her medications regularly for 3/52.Difficulty in doing her ADLs, medications regularly for 3/52.Difficulty in doing her ADLs, sleeping downstairs.sleeping downstairs.

BG-Lives alone, independent, PDBG-Lives alone, independent, PD Meds Quetiapine, Rasagiline, Sinemet-Plus.Meds Quetiapine, Rasagiline, Sinemet-Plus. O/e-large built lady, Obs-stable, oedema-ankles and legs, under O/e-large built lady, Obs-stable, oedema-ankles and legs, under

arms, groin and infra-mammary regions-excoriated , inflamed, arms, groin and infra-mammary regions-excoriated , inflamed, gait-short steps.gait-short steps.

How would you manage this patient?How would you manage this patient?

Lighter moments….Lighter moments….