One of the most common reason for seeking a cardiovascular consultation is leg edema- swelling, puffiness of the feet, legs and hands, caused by excess fluid trapped in your body.

Mild edema can be caused by prolonged standing or walking, mostly in hot weather and resolves by itself with leg elevation and rest.

More severe or recurrent edema can be a sign of heart failure or DVT- blood clots , which require medical attention and treatment.

As we get older, edema is triggered by multiple causes, such as Obstructive Sleep Apnea, (OSA), obesity, venous insufficiency , uncontrolled hypertension.

Addressing only one of the above will result in only minimal improvement and .. patient’s dissatisfaction ; therefore, a full understanding of multiple causes of edema is important.

Causes of Edema

1. New onset Hypertension; at the beginning, HTN may fluctuate, triggering intermittent leg edema; Blood pressure readings may not be high all the time, and may be dependent on your salt intake, activity level. Simple control of Blood pressure, will cure edema.

2. Obesity, inactivity, high salt intake are commonly associated with edema

3. Heart failure, may start with persistent, not position dependent leg swelling, associated with shortness of breath, tiredness, fatigue, weight gain. Full cardiac evaluation , starting with an echo-cardiogram, is mandatory. Edema is soft and the skin retains the indentation caused by fingertip pressing – called “pitting edema”

Typical pitting edema in Heart Failure

1. Blood clots, or DVT- Deep venous thrombosis. Clots that form in the veins of the legs can stop the return flow of blood from the legs back up to the heart and cause swelling in the ankles and feet. Blood clots can be either superficial (occurring in the veins just beneath the skin), or deep (a condition known as DVT .These blood clots can be life-threatening if they break loose and travel to the heart and lungs. Swelling in one leg, is usually associated with pain, low-grade fever, change in color of the affected leg. Immediate diagnosis and treatment with blood thinners is necessary.

2. Obstructive Sleep Apnea- OSA – is a common offender and even after treatment with CPAP, edema may persist, requiring long term diuretics, such as Lasix or Bumex

1. Venous insufficiency or Varicose veins. Swelling of the ankles and feet is often an early symptom of venous insufficiency, a condition in which blood inadequately moves up the veins from the legs and feet up to the heart. Normally, the veins keep blood flowing upward with one-way valves. When these valves become damaged or weakened, the blood leaks back down the vessels and fluid is retained in the soft tissue of the lower legs, especially the ankles and feet. Chronic venous insufficiency can lead to skin changes, skin ulcers, and infections. Edema is many times present without visible varicose veins.

Edema in Venous Insufficiency, without visible varicose veins

1. Significant lung conditions, even COPD, or Emphysema, are known to trigger Right side Heart Failure, with hard to treat leg edema. Gravity causes fluid to accumulate more in the feet and ankles, but fluid can also accumulate in the abdomen and chest causing increased abdominal girth.

2. Abnormal thyroid function, mostly Hypothyroidism will cause generalized weight gain, and puffiness, affecting not only the legs but hands, arms, faces, periorbital area. Diuretics will not work, unless thyroid function is restored. 

3. Kidney disease can also cause foot and ankle swelling. When kidneys are not functioning properly, fluid can build up in the body.

4. Lymphedema. This is a collection of lymphatic fluid in the tissues that can develop because of the absence of or problems with the lymph vessels or after the removal of lymph nodes. It is common following radiation therapy or removal of the lymph nodes in patients with Cancer. In contrast to venous insufficiency, this type of edema does not fluctuate with dependent positions. It’s called a “nonpitting edema”- it is firm, and the skin does not retain its displacement when indented with a fingertip.

Non pitting, firm edema in Lymphedema

1. Medication side effect. Many drugs can cause swelling in the feet and ankles as a possible side effect. Common offenders are:

• amlodipine, nifedipine, diltiazem and most of the Calcium blockers used for HTN. 

• steroids

• hormones, such as estrogen, ( found in contraceptive drugs)

• many antidepressants- nortriptyline, desipramine, phenelzine

• non-steroidal anti-inflammatory drugs, NSAIDS, such as ibuprofen

• some of the Diabetes medications. 

Treatment of Edema

• Avoid prolonged standing and obesity. Wear compression stockings when possible

• Avoid salt. There are multiple alternative to table salt, but most of them contain the same amount of Sodium, then there is no benefit. Low salt alternatives may be a good option, since they taste the same as table salt, but use Potassium instead of Sodium. Caution is necessary with extra Potassium .

• Most of the time, diuretics are necessary. Commonly used are Furosemide ( lasix), Bumetadine, ( bumex) and Torsemide. The HCTZ used as blood pressure pill offers a minimal amount of diuresis.

• Diagnose and treat the underlying condition, ( heart failure, OSA, HTN.)