Clinical Studies
Etiology and diagnosis of bilateral leg edema in primary care

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Abstract

Purpose: To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter.

Patients and Methods: Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses.

Results: Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common.

Conclusions: Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Section snippets

Methods

Patients were enrolled at an inner city family practice in Cleveland, Ohio, between March 1993 and February 1996. The practice is staffed by five family physicians and a family nurse practitioner. The practice population is primarily Caucasian or Hispanic, and mostly working class or indigent.

Ambulatory patients 18 years of age and older who had bilateral leg edema were eligible for enrollment, regardless of the duration of the edema, any previous diagnoses, laboratory tests, or radiological

Results

Fifty eight patients enrolled in the study, 13 of whom did not complete the echocardiogram and venous duplex scans. Of the remaining 45 patients, 43 had pitting edema and 2 had nonpitting edema. Patients’ ages ranged from 29 years to 83 years (Table 1). One third had edema for less than 6 months, and 30% reported edema lasting more than 6 years. Eighty-four percent of the subjects were obese.

There were no significant differences between the patients who completed the study and those who did not

Discussion

We found a higher rate of both cardiac disease and pulmonary hypertension in patients with bilateral lower extremity edema than was initially suspected by the primary care provider. Many of the characteristic signs and symptoms of congestive heart failure were absent in many patients with echocardiographic evidence of cardiac disease. Ambulatory patients with cardiac disease may present with edema at a relatively early stage, before the other signs and symptoms of congestive heart failure

Acknowledgements

The authors would like to acknowledge the support of Nicholas Davis, BM, BCh, Ann Reichsman, MD, and Heather Ways, MD; the contributions of Maureen Babjak, Linda Hall, and Lynn Steppke; and manuscript assistance from Robert Bahler, MD, Louis Rakita, MD, and Ed Ricanati, MD.

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