A 63-year-old woman comes to the office due to leg swelling that is especially bothersome in the evening. Her symptoms have gradually worsened over the last year. Her medical problems include hypertension treated with lisinopril and obstructive sleep apnea for which she uses continuous positive airway pressure during sleep. She was hospitalized 2 years ago for a chest infection that was treated with antibiotics. The patient has smoked a pack of cigarettes daily for 30 years and does not drink alcohol. Blood pressure is 160/90 mm Hg and pulse is 80/min. BMI is 32 kg/m2. Jugular venous pulsation is seen 2 cm above the sternal angle with the head of the bed elevated to 45°. Chest examination shows bilateral scattered wheezes and prolonged expirations. Her abdomen is soft and nondistended. She has bilateral 2+ pitting edema in her lower extremities to the midshin with dilated and tortuous superficial veins. A small ulcer is noted on the left medial ankle. All peripheral pulses are palpable. Which of the following is most likely to relieve this patient's current symptoms?
This patient's lower extremity (LE) swelling is likely due to chronic venous insufficiency (CVI), which is most commonly caused by incompetence of venous valves leading to venous hypertension in the deep venous system of the legs. Patients may present with leg discomfort, pain, or swelling that is typically worse in the evening or following prolonged standing and improves after walking or leg elevation. Pitting edema is the most common physical examination finding. In relatively severe cases, redirection of blood from the deep venous system to the superficial venous system may lead to other physical examination findings, including abnormal venous dilation (eg, telangiectasia, varicose veins), skin discoloration, lipodermatosclerosis, or skin ulceration (characteristically on the medial aspect of the lower leg). Risk factors for CVI include advancing age, obesity, family history, pregnancy, sedentary lifestyle, previous LE trauma, and previous LE venous thrombosis.
The diagnosis of CVI is usually based on history and physical examination, and initial treatment includes leg elevation, exercise, and compression stockings. Patients who do not respond to initial conservative measures should undergo venous duplex ultrasound to confirm the diagnosis of CVI by identification of venous reflux (retrograde venous blood flow) in the deep venous system.
(Choice A) Diuretics (eg, furosemide) are useful in the management of heart failure, which is unlikely in this patient given the lack of dyspnea and the normal jugular venous pressure. Diuretics are likely to cause dehydration in patients with CVI and are generally not recommended.
(Choices B and D) Dietary sodium restriction and hypertension control are important interventions in the management of LE edema due to heart failure, but do not play a significant role in the management of CVI. This patient's normal jugular venous pressure and absence of crackles on lung examination (wheezing is likely due to underlying chronic obstructive pulmonary disease rather than pulmonary edema) make heart failure unlikely.
(Choice E) Smoking is considered a risk factor for CVI; however, there is no evidence to support smoking cessation as an effective management strategy for CVI. Smoking cessation is a first-line intervention for peripheral arterial disease, which does not cause significant LE edema and is unlikely in this patient with palpable peripheral pulses.
Educational objective:
Chronic venous insufficiency is a common cause of lower extremity edema that may be accompanied by varicose veins, skin discoloration, and medial skin ulceration. Initial treatment includes conservative measures with leg elevation, exercise, and compression therapy.