Bilateral leg edema

In morning report today we discussed a case of a  patient presenting with progressive bilateral leg edema.

Just based on this complaint alone we found that a differential was generated with cardiac, renal, hepatic, structural, and medication causes being cited first. 

As with any case, we will move from type A and type B reasoning to come to a conclusion. Analytical reasoning and pattern recognition will interplay in our minds as we work through a case.

This patient had signs and symptoms that were ultimately consistent with right sided heart failure in the absence of evidence of left sided disease.

Isolated right heart failure often raises the question of whether the person has pulmonary hypertension.

We went through clues for this on physical and investigations.

Physical exam findings of pulmonary hypertension include:

On inspection: an elevated JVP

On palpation of the precordium: Palpable P2, RV heave, thrill of TR

On auscultation of the precordium: Loud P2, widely split S2, TR murmur, right sided S3,4

ECG findings of pulmonary hypertension include

RBBB

P pulmonale

RVH

RAD

Additionally, one of his findings on exam was a pulsus paradoxus.

Remember that a pulsus paradoxus is the change in systolic pressure with respiration.

As we inspire, we increase right sided filling, and ventricular interdependence can lead to a shift from right to left and in pathologic situations, can lead to a decrease in left sided filling, and subsequently a decrease in CO. This explains why with inspiration, the Korotkoff sound disappears as there is no flow through the systemic circulation.

Remember there is a DDx to pulsus paradoxus including...

1. Pericardial disease

2. Cardiomyopathy

3. Severe RHF

4. Obstructive lung disease

In this person, we discussed ventricular interdependence and how increased filling pressures can lead to a right to left shift, and thus decrease CO.

This person did NOT have tamponade, and so gentle diuresis was carried out with improvement in his renal blood flow and decrease in his symptoms.

Important to note that in this case diuresis was appropriate, but in true tamponade, diuresis will decrease intraventricular pressures that are normally overcoming pericardial pressures and this can lead to hemodynamic collapse.