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Dr My Leg/Legs Are Swollen… Dr Rashmi Gaekwad RDH 20 th April 2011.

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Presentation on theme: "Dr My Leg/Legs Are Swollen… Dr Rashmi Gaekwad RDH 20 th April 2011."— Presentation transcript:

1 Dr My Leg/Legs Are Swollen… Dr Rashmi Gaekwad RDH 20 th April 2011

2 Foot, leg and Ankle swelling--Causes Heart Failure Liver Failure Renal Failure DVT, CVI, Varicose Veins, Surgery, Lymphoedema Starvation, Malnutrition, Insect Bite/Sting, Burns Obstruction Hormones-oestrogen (OCP,HRT)/Testosterone Calcium Channel Blockers- Nifedipine, amlodipine, Diltiazem, Felodipine, Steroids, NSAIDs Antidepressants- MAO Inhibitors, Tricyclics (Amitry, Nortr, Desipramine)

3 How are you going to explain it to your patients? The Heart Pumps blood through the arteries under high pressure. The Heart Pumps blood through the arteries under high pressure. This pressure is lost and blood relies in simple back pressure to move to the heart.\This ia aided by muscle activity, squeezes the veins and pushes blood along. This pressure is lost and blood relies in simple back pressure to move to the heart.\This ia aided by muscle activity, squeezes the veins and pushes blood along. When muscle movement is lost, it is harder to get the blood back up from the legs. When muscle movement is lost, it is harder to get the blood back up from the legs. Water Seeps from distended veins into surrounding tissues and legs and feet swell. Water Seeps from distended veins into surrounding tissues and legs and feet swell. Repeated episodes of swelling, veins become more leaky. Repeated episodes of swelling, veins become more leaky. One way valves in the veins are collapsing under the weight of all the blood, pooled on top of them One way valves in the veins are collapsing under the weight of all the blood, pooled on top of them The swelling gets worse The swelling gets worse Complications: Complications: Needles and pins sensation-poor microcirculation Needles and pins sensation-poor microcirculation Lousy circulation causes blood to clot Lousy circulation causes blood to clot Clot can impede circulation Clot can impede circulation Break loose-travel to the Brain-Stroke, Lungs- Pulmonary Embolus, Break loose-travel to the Brain-Stroke, Lungs- Pulmonary Embolus,

4 Heart Failure Causes: High Output-Hyperthyroidism, Anaemia, AV Mal Low Output-Preload, Pump Failure, After load RHF-PHTN,TR

5 BACKGROUND Complex syndrome caused by impaired cardiac function Complex syndrome caused by impaired cardiac function Two types: left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF) Two types: left ventricular systolic dysfunction (LVSD) and heart failure with preserved ejection fraction (HFPEF) Most common cause: coronary artery disease Most common cause: coronary artery disease 30–40% of patients die within a year of diagnosis 30–40% of patients die within a year of diagnosis Prevalence Prevalence Around 900,000 people in the UK, average age-76yrs Around 900,000 people in the UK, average age-76yrs expected to rise in the future expected to rise in the future GP HF register-average 10 pts new diagnosis, 30pts per GP GP HF register-average 10 pts new diagnosis, 30pts per GP

6 Symptoms/Signs LVF-SOB,NOCTURAL COUGH/WHEEZE, LETHARGY/FATIGUE, JVP,HEPATOMEGALY, ASCITES.BASAL- CREPITATIONS, EFFUSIONS, WHEEZE.CARDIOMEGALY, PULSUS ALTERNANS.

7 Diagnosis In patients with symptoms and signs of heart failure: Measure serum natriuretic peptides in patients without previous MI Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks if previous MI BNP > 400 pg/ml or NTproBNP > 2000 pg/ml Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks if: Refer to have transthoracic Doppler 2D echocardiography and specialist assessment within 6 weeks if: BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml BNP 100 – 400 pg/ml or NTproBNP 400 – 2000 pg/ml If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an untreated patient If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an untreated patient BNP-Raised in LVH, PE, Renal Dysfunction, Sepsis, COPD, >70yrs, Cirrhosis, DM BNP-Raised in LVH, PE, Renal Dysfunction, Sepsis, COPD, >70yrs, Cirrhosis, DM

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9 When to refer to the specialist MDT for the initial diagnosis of heart failure for 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 home heart failure that can no longer be managed at home when they are planning a pregnancy or are pregnant when they are planning a pregnancy or are pregnant when they have heart failure due to valve disease when 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 Arrhythmias Angina, AF, Symptomatic Arrhythmias

10 Mgmt-non drug measures Patient -educate, Rx, prognosis, written plan-Self-care confidence, maintenance & management Patient -educate, Rx, prognosis, written plan-Self-care confidence, maintenance & management Diet-low salt adequate calories, restrict alcohol, loose weight if obese Diet-low salt adequate calories, restrict alcohol, loose weight if obese Restrict fluid intake in severe HF Restrict fluid intake in severe HF Lifestyle measures: Smoking cessation, regular exercise Lifestyle measures: Smoking cessation, regular exercise Vaccination: Influenza (yrly) and Pneumococcal (once) Vaccination: Influenza (yrly) and Pneumococcal (once) Air Travel-depend on their clinical condition Air Travel-depend on their clinical condition Assess for depression Assess for depression

11 Mgmt-pharmacological Offer both ACE inhibitors and beta-blockers licensed for heart failure to all patients with LVSD Offer beta-blockers licensed for heart failure to all patients with LVSD, including older adults and pts with Offer beta-blockers licensed for heart failure to all patients with LVSD, including older adults and pts with peripheral vascular disease peripheral vascular disease erectile dysfunction erectile dysfunction diabetes mellitus diabetes mellitus interstitial pulmonary disease interstitial pulmonary disease COPD without reversibility COPD without reversibility 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: aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month) aldosterone antagonist licensed for heart failure (especially in NYHA class III–IV or MI in past month) ARB licensed for heart failure (especially in NYHA lclass II-III) ARB licensed for heart failure (especially in NYHA lclass II-III) hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHA class III-IV) hydralazine in combination with nitrate (especially in people of African or Caribbean origin with NYHA class III-IV)Digoxin-AF+HF Anticoagulation-Thromboembolism, LV aneurysm Aspirin-Atherosclerotic arterial disease (CHD) Statins, Amiodarone, Spironolactone,

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13 Monitoring/Rehab All patients with chronic heart failure require monitoring. This monitoring should include: a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status a review of medication, including need for changes and possible side effects a review of medication, including need for changes and possible side effects serum urea, electrolytes, creatinine and eGFR serum urea, electrolytes, creatinine and eGFR When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure

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15 Case 1 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 has been c/o chest pain, right shoulder pain. 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 has been c/o chest pain, right shoulder pain. BG-had THR ®, Lives with his wife, quite independent., never smoked BG-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 oedema O/E- temp of 37.4,sats-94% bi-basal crackles, pedal oedema How would you manage this patient? How would you manage this patient?

16 Case 2 Home visit –Mrs MF 68 yrs old -swelling of legs, decreased mobility and sore creases for 3 weeks. Poor sleep. Not taking her medications regularly for 3/52.Difficulty in doing her ADLs, sleeping downstairs. Home visit –Mrs MF 68 yrs old -swelling of legs, decreased mobility and sore creases for 3 weeks. Poor sleep. Not taking her medications regularly for 3/52.Difficulty in doing her ADLs, sleeping downstairs. BG-Lives alone, independent, PD BG-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 arms, groin and infra- mammary regions-excoriated, inflamed, gait-short steps. O/e-large built lady, Obs-stable, oedema-ankles and legs, under arms, groin and infra- mammary regions-excoriated, inflamed, gait-short steps. How would you manage this patient? How would you manage this patient?

17 Lighter moments….


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