Chapter(8(*(The(importance(of( differen4a4ng(leg(edema(from( venous(insufficiency(versus(that(of( conges4ve(heart(failure( Ariel(D.(Soffer,(MD,(FACC( Faith(Jaslow,(ARNP( (
Welcome'to'the'Vein'Experts'Online' Educa6onal'CME'Program.( Original'Release'Date:'11/25/13( Termina6on'Date:'1/31/2016( Price:((25.00(for(Vein(Experts(Members(&( $40.00(for(Non*Members(*(Processing/CME(Fees(
• ''This(ac4vity(has(been(planned(and(implemented(in(accordance( with(the(accredita4on(requirements(and(policies(of(the( Accredita4on(Council(for(Con4nuing(Medical(Educa4on((ACCME)( through(the(joint(providership(of(The(University(of(Toledo(and( VeinExperts.org.( • The(University(of(Toledo(is(accredited(by(ACCME(to(provide( con4nuing(medical(educa4on(for(physicians.( • ( The(University(of(Toledo(designates(this(enduring(ac4vity(for(a( maximum(of(1.00(AMA#PRA#Category#Credits™.((Physicians(should( claim(only(credit(commensurate(with(the(extent(of(their( par4cipa4on(in(the(ac4vity.( ((
For(nurses,(we(are(also(able(to(issue(a(cer4ficate(of(aZendance(sta4ng(the(course(is(AMA(approved,( which(may(be(eligible(for(credit.((Nurses(are(responsible(for(submi[ng(the(cer4ficate(to(their(board.(( Please(note(only(one(cer4ficate(can(be(issued(for(each(purchase.( ( Disclosures:( ( Peggy'Bush,'APN,(planning(member,(has(no(disclosures(or(financial(interests(and(is(contracted(by( Water’s(Edge(Dermatology(and(Soffer(Health.(' Ronald'Bush,'MD,'FACS,(faculty(and(planning(member(discloses(he(is(on(the(Speaker’s(Bureau(for( Dornier/Refine(USA(and(is(contracted(with(Water’s(Edge(Dermatology(and(Soffer(Health.(( Faith'Jaslow,'ARNP,(faculty,(has(not(financial(interest(or(other(rela4onships(with(any(manufacturer(of( commercial(product(or(service(to(disclose.(( Richard'L.'Mueller,'MD,(faculty(and(planning(member,(discloses(he(receives(grant/research(support(from(Vascular( Insights,(LLC(
Becky'Roberts,(planning(member,(has(no(financial(interest(or(other(rela4onships(with(any( manufacturer(of(commercial(product(or(service(to(disclose( Ariel'Soffer,'MD,(FACC,(faculty(and(planning(member,(discloses(he(is(on(the(Speaker’s(Bureau(for( Cutera(,(consults(for(Angiodynamics,(&(does(research(for(BTG.(
Mission:( (Our(objec4ve(is(to(provide(current(evidence(based( informa4on,(as(well(as(new(technology(that(is(being( developed(for(the(treatment(of(venous(disease(presented( in(a(virtual(format.(( (( Target'Audience:( (The(target(audience(for(this(ac4vity(includes(physicians( and(other(health(care(professionals(in(Cardiology,( Dermatology,(Interven4onal(Radiology,(Phlebology,( Surgery,(Vascular(Surgery,(Wound(Care(Specialists(who( care(for(pa4ents(with(venous(disease.((
Steps'to'successfully'complete'this'ac6vity:( CME'Credit'Instruc6ons( Steps'to'successfully'complete'this'ac6vity:( Register(for(CME(ac4vity(&(pay(your(CME(fees.( Read(the(Vein(Journal(Chapter(8,(en4tled(‘The'importance'of' differen6a6ng'leg'edema'from'venous'insufficiency'versus'that'of' conges6ve'heart'failure.’'' Take(the(post(test((score(of(80%(or(greater(must(be(achieved.((A(pdf( copy(of(the(exam(can(be(emailed(to(you(if(requested).( Scan(and(email(post(test(and(evalua4on(to((pbush@veinexperts.org(or( you(can(fax(completed(paperwork(to(937*281*0200.(( You(will(be(contacted(by(the(University(of(Toledo(CME(office(for( instruc4on(of(how(to(sign(on(and(print(your(cer4ficate.((
Technical(Support( Email(your(ques4ons/concerns( to(pbush@veinexperts.org((or(you(can(call(us( at(407*900*8346(and(we(will(respond(in(24( hours.( (( '(
Objec4ves:( • Recognize(causes(for(leg(edema( • Describe(accurate(ways(of(tes4ng(for(leg(edema( to(determine(the(primary(cause( • Iden4fy(the(common(causes(of(Venous( Insufficiency( • Iden4fy(the(common(causes(of(Conges4ve(Heart( Failure( • Recognize(appropriate(treatment(plans(for( conges4ve(heart((failure(vs.(venous(insufficiency(
Edema(–(CHF(vs.(VI( • In(the(United(States,(the(most(common(diagnosis( for(hospital(admission(is(Conges4ve(Heart(Failure( or(CHF( • One(of(the(most(common(signs(of(CHF(is(leg( swelling((edema)( • One(of(the(most(common(circulatory(disorders( (albeit(woefully(undiagnosed(at(less(than(10%(of( affected(people(have(been(iden4fied)(is(venous( insufficiency(which(is(commonly(associated(with( edema(
Importance(of(Proper(Diagnosis( • Unfortunately(for(clinicians(and(pa4ents(the( treatment(of(these(two(forms(of(edema(are( completely(different,(and(therefore(mistaken( diagnoses(and(treatments(can(be(disastrous(to( our(en4re(health(system((see(Figure(1).( • (Thankfully,(the(advances(in(clinical(tools(such( as(Doppler(Ultrasonography(have(made( diagnosis(and(differen4a4on(of(these( disorders(readily(available.(
Figure(1(
Edema( VI(
CHF(
VENN'DIAGRAM' ' • ##The#intersec7on#of#VI#(venous#insufficiency)#and#CHF#(conges7ve#heart#failure)#with#Edema#represents#an# important#and#challenging#area#of#differen7a7on.( • ##The#large#areas#of#Edema#with#VI#alone#(without#any#CHF)#represent#areas#of#medicine#that#have#poten7ally# easily#curable#Edema#and#should#not#be#mistaken#for#the#less#curable#CHF#that#is#treated#completely# differently.((( (
Primary(Causes(of(Leg(Edema( • Veins(in(the(legs(are(responsible(for(transpor4ng(blood(up(to(the( veins(of(the(torso,(where(it(is(then(returned(to(the(heart.( • The(veins(of(the(legs(have(valves(that(prevent(the(backward(flow(of( blood(within(them.(( • Venous(insufficiency((VI)(is(incompetence(of(the(veins(that(occurs( because(of(dila4on,(or(enlargement,(of(the(veins(and(dysfunc4on(of( their(valves.( • VI(leads(to(a(backup(of(blood(and(increased(pressure(in(the(veins,( thereby(resul4ng(in(edema(of(the(legs(and(feet( • Edema(of(the(legs(also(can(occur(with(an(episode(of(deep(vein( thrombosis((DVT),(which(is(a(blood(clot(within(a(vein( • A(clot(in(the(deep(vein(blocks(the(return(of(blood,(and(consequently( causes(increased(back*pressure(in(the(leg(veins( • It(is(also(postulated(that(VI(can(be(an(independent(risk(factor(for( DVT,(which(can(be(a(very(dangerous(condi4on(
Con4nua4on(of(Primary(Causes(of(Leg( Edema( • VI(is(a(problem(that(is(localized(to(the(legs,(ankles,(and(feet.(One(leg(may( be(more(affected(than(the(other((asymmetrical(edema).(( • Open(both(legs(are(simultaneously(affected(as(the(underlying(anatomic( pathology(open(is(mimicked(bilaterally.((( • In(contrast,(systemic(diseases(that(are(associated(with(fluid(reten4on( (most(common(one(being(conges4ve(heart(failure)(almost(always(cause( the(same(amount(of(edema(in(both(legs,(and(can(also(cause(edema(and( swelling(elsewhere(in(the(body.(( • The(response(to(therapy(with(diure4c(drugs(in(pa4ents(with(venous( insufficiency(tends(to(be(unsa4sfactory.(This(is(because(the(con4nued( pooling(of(fluid(in(the(lower(extremi4es(makes(it(difficult(for(the(diure4cs( to(mobilize(the(edema(fluid.( • (Eleva4on(of(the(legs(periodically(during(the(day(and(the(use(of( compression(stockings(may(temporarily(help(the(condi4on,(but(ul4mately( venous(insufficiency(is(a(mechanical(problem(that(responds(to(mechanical( solu4ons(commonly(performed(today(such(as(thermal(or(chemical(energy( abla4on.(
Common'Causes'of'Venous'Insufficiency:(
(
There(are(several(condi4ons(than(can(cause(the(valves(and(veins(to( work(improperly:( • Any(problem(that(increases(pressure(in(the(veins(in(the(legs(can( stretch(the(veins.(This(can(damage(the(valves,(which(leads(to(even( higher(pressures(and(worsened(vein(func4on.( • A(clot(in(a(vein(will(block(blood(flow(back(through(the(vein,(which( can(increase(pressures,(open(permanently(damaging(the(vein(or( valves(even(aper(the(clot(has(dissolved.( • Leg(injury(or(surgery(can(damage(the(veins(or(valves.( • Increased(body(weight((eg,(pregnancy,(obesity)(can(increase( pressure(in(the(veins(of(the(legs,(and(this(can(usually(irreparably( damage(the(veins(and(valves.( • The(muscles(in(the(legs(play(an(important(role(in(the(circula4on(of( blood,(ac4ng(as(a(pump.(Standing(or(si[ng(for(prolonged(periods( without(walking(can(decrease(the(movement(of(blood(out(of(the( legs(and(lead(to(increased(pressures(in(the(veins(and(pooling(of( blood(
Common'Causes'of'Conges6ve'Heart'Failure:(
(
• Coronary(Artery(Disease( • High(Blood(Pressure((Hypertension)( • Diseases(of(the(heart(muscle( (Cardiomyopathy)( • Disorders(of(the(heart(valves(
Conclusion:( ( • Edema(of(the(legs(is(a(very(common(and( uncomfortable(sign(of(underlying(disease.(( • With(the(advent(of(Doppler(Ultrasonography,(accurate( diagnosis(and(appropriate(treatment(can(be(readily( administered.(( • As(the(common(causes(and(treatment(paradigms(are( very(different(for(the(two(most(frequent(causes(of( edema((CHF(and(VI)(it(is(very(important(that(proper( diagnoses(are(made.(( • More(research(on(this(topic(appears(to(be(warranted( for(poten4al(pa4ent(benefit(and(health(system( op4miza4on.(((
1.(Meir,(P.,(Tabencki,(S.,(Rose,(H.,(&(Spigleman,(A.,( Nonvascular(Pathology(iden4ďŹ ed(by(duplex(scanning( during(tes4ng(for(venous(thrombosis(in(the(edematous( and/or(painful(lower(extremity.(Journal#of#Vascular# Technology,##1999#23(4),197*200.( 2.(Zygmunt,(J.(What(is(new(in(duplex(scanning(of(the( venous(system.(Perspec7ves#in#Vascular#Surgery#and# Endovenous#Therapy,#21(2),#94*104( 3.(St.(Anna,(L.(What(is(the(dieren4al(diagnosis(of(chronic( leg(edema(in(primary.(Journal#of#Family#Prac7ce.( ((
Exam( Complete'the'exam'&'evalua6on'below'and' email'your'results'to'pbush@veinexperts.org' along'with'your'contact'informa6on.'( '( A'score'of'80%'or'greater,'must'be'achieved'on' the'post`test'and'be'completed'in'less'than'3' aaempts.''
Venous(Insufficiency(is(associated(with(leg(edema(is( commonly(undiagnosed.(Approximately(was( percentage(of(people(have(been(iden4fied?( A. B. C. D.
( (
5%( 10%( 25%( 35%(
Venous(Insufficiency(and(Conges4ve(Heart(Failure(are( completely(different(and(therefore(appropriate( diagnosis(is(extreme(important.(What(test(would(you( order(to(rule(of(VI(vs.(CHF?( A. B. C. D.
(
CT(Scan( Echocardiogram( Venous(Doppler(Ultrasonography( Stress(Test(
What(is(the(defini4on(of(venous( insufficiency?( A. A(condi4on(of(incompetence(of(the(veins(that(occur( because(of(dila4ons(and(dysfunc4on(of(the(valves.( B. A(condi4on(of(large,(dark(veins(that(tend(to(bulge(but( are(not(severe(enough(to(require(surgical(treatment.( C. A(condi4on(of(abnormally(large(fluid(volume(in(the( circulatory(system(or(in(4ssues(between(the(body’s( cell.( D. A(condi4on(marked(by(weakness,(edema(and( shortness(of(breath(that(is(caused(by((the(inability(of( the(heart(to(maintain(adequate(blood(circula4on(in( the(peripheral(4ssues(and(the(lungs(
What(are(common(causes(of(venous(insufficiency?(
A. Coronary(Artery(Disease( B. Hypertension( C. Disorder(of(heart(valves( D. Leg(Injury(
What(is(the(ul4mate(way(to(treat(venous(insufficiency?(
A. Thermal/Chemical(abla4on( B. Compression(stockings( C. Diure4cs( D. Ibuprofen(therapy(
(
Evalua4on( (( How(well(did(this(ac4vity(present(the(objec4ves?( (( Excellent((Good( ( (Sa4sfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(usefulness(of(the(online(material(to(mee4ng(your(needs?(( (( Excellent((Good( (( (Sa4sfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(presenta4on(material?(( (( Excellent((Good( ( (Sa4sfactory( ( (Poor(( (( (
Was(any(commercial(bias(presented(in(the(material?(( ( No( (Yes((Please#explain)#(( ____________________________________________________(( (( I(will(be(able(to(change(my(clinical(prac4ce(as(a(result(of(par4cipa4ng(in(this(ac4vity.( (( Yes( (No(( (( (( What(topics(about(venous(disease(would(you(like(to(hear(about(in(the(future?(( (( ____________________________________________________(( ((( (( (
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Contact'Informa6on( ( '( Name(&( Creden4als_______________________________________________( (( Address( ________________________________________________________( (( Phone(Number( ___________________________________________________( (( Email(address(___________________________________( ((
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