Q: My husband’s feet and lower legs started swelling a few months ago. He went to an internist who is in his second year of practice. He had blood work and several tests to rule out heart trouble and blockages. The doctor said everything came back normal, including the kidneys and thyroid. He prescribed a water pill and it didn’t help. The swelling is still there and my husband is now feeling worse. He has shortness-of-breath.
Do you have any advice as to what we should to next?
A: The causes for foot and ankle edema are many. The most common systemic diseases involve the kidneys, liver and heart – essentially because of the body’s retention of too much sodium. Excess salt can cause the body to retain water which then leaks into interstitial tissue space and results in edema. If the flow of blood to the kidneys is decreased by heart failure, the kidneys react by retaining salt. An inefficient heart cannot pump blood adequately through the lungs, causing a person to become short of breath as fluid accumulates in the lungs.
Other than a water pill, you don’t indicate if your husband is on any other medication such as a calcium channel blocker or NSAIDs (non-steroidal anti-inflammatory drugs) that could have edema as an unwanted side effect. Up to half of all patients on calcium channel blockers develop edema. My guess is that the medication aspect should have been covered when he saw his physician but if not, you should make a list to present to him or her for review.
Then there are bad dietary choices including eating foods such as potato chips or salting foods heavily (sometimes even prior to tasting them), indulging in anchovies, eating canned soups, many of which are high in sodium, consuming cold cuts from the deli on an all too regular basis, and much, much more.
While you indicate his heart was checked, heart failure a/k/a CHF is a condition in which the heart fails to pump blood sufficiently throughout the body. This situation may cause a buildup of fluid in the feet, ankles and legs. CHF is more common in seniors than in younger individuals, in those who have had a heart attack, and in people who are obese. While obesity itself does not cause leg edema, the excess weight can lead to lymphedema, idiopathic edema, chronic venous insufficiency, and more. Men are more likely to develop CHF than are women.
Venous insufficiency presents with pitting edema. The individual with a venous insufficiency may have varicose veins. While most patients remain asymptomatic, a sensation of heaviness can occur. A clinical diagnosis may be made; however, confirmation with imaging testing known as a Doppler ultrasound may be used for confirmation.
I can appreciate that your husband’s doctor indicated his heart and thyroid are working well but patients over the age of 45 who suffer from extremity edema of uncertain etiology might consider having an echocardiogram to rule out pulmonary hypertension, heart failure, or other cardiac abnormalities. Your husband should ask about wearing compression stockings which might help the edema but are contraindicated for arterial insufficiency.
Edema can be temporary or it may be permanent depending on its cause. Treatment will depend on the underlying cause which must be determined. If your husband smokes, he should discontinue the practice. If he is on medication for high blood pressure, he should speak with his physician regarding the possible side effects. While he may not be able to discontinue the medication, he might be able to substitute it for another drug. He should put a pillow under his legs and feet when lying down so his legs are higher than his heart. In fact if he can do this three or four times each day, it might help.
Ask for a referral to a cardiologist since the odds are that this problem is cardiac related. If it isn’t, then the cardiologist can recommend a pulmonologist, but don’t be put off by the doctor’s age. An older physician may be able to pull a few tricks out of his hat but a younger one has the benefit of newer technology and cutting edge training.
