International consensus on Lipoedema - why we needed this paradigm shift
Compression therapy uses the technique of controlled pressure to increase blood flow in the legs. It helps to improve blood flow in the heart, supports veins and decreases swelling in lower extremities. However, there are some risks that were explained by Dr. Tobias Hirsch.
Risk and complications of compression therapy:
- Oedema drainage and cardiac insufficiency
- Borderline Indications
He started by presenting a case study of Ottilie, a 75-year-old woman. She suffers from coronary heart disease, atrial fibrillation, and heart failure in NYHA stage two. Another problem is lymphedema in her right leg. Can she receive compression therapy and lymphatic drainage despite her heart insufficiency?
The causes of heart failure are:
- Hypertensive heart disease
- Coronary heart disease
- Heart valve defect
- Cardiac arrhythmia
Affected persons suffer from dyspnea, nocturia, fatigue, cyanosis, and bilateral edema. The most critical symptom is dyspnea since it is potentially life-threatening. We distinguish between four degrees of heart insufficiency based on the international classification of diseases:
- Grade 1 means there are no limitations and symptoms under regular activity
- Grade 2 means slight limitations
- At grade 3 symptoms begin in ordinary activity cardiac decompensationare but patients are still comfortable at rest.
When they reach grade 4, patients cannot conduct any activity and sometimes have symptoms at rest.
Dr Bertsch illustrated a compression homunculus diagram showing the venous pooling in the legs and the right atrium. The right ventricle, and the left ventricle with the arterial branch, observing the vein of the leg and the right heart once putting on a compression stocking in the worst-case pulmonary edema can develop and this is the problem the redistribution of blood volume.
Only a fraction of the blood reaches the right heart because of the elastic properties of the inferior vena cava; in addition, changes in heart rate adjust the cardiac output to compensate for the increased load. Going back to the Ottilie case, are we allowed to decongest Ottilie?
European guidelines for heart failure published a list of factors that cause decompensation of heart insufficiency; they do not list compression and lymphatic drainage.
We must establish this in our patient history, that is always the most important thing. We can ask
- Do you suffer from dyspnea?
- Can you sleep in a flat position?
- Did you tolerate lymphatic drainage and compression stockings?
- Do you suffer from breathlessness?
We have the examination of bilateral edema, which is typical for heart failure . There is another excellent tool, NT- proBNP; it is a biomarker that marks the cardiac burden; the standard NT-pro-BNP rules our heart failure. A German review from 2017.
Called indications and clinical implications of using the cardiac markers BNP and NT-proBNP, we can feel free to treat Ottilie.
There is little data about biomarkers and compression, and they used HANP (Human Atrial Natriuretic Peptide), which is related to BNP and anti-probing the marker rises only a short time with NYHA. However, all patients indicated stable hemodynamic and cardiac function. Compression therapy is considered harmless in patients with cardiac insufficiency NYHA stage two.
In another paper from Belgium, they investigated NYHA stage 3 & 4 patients in the intensive care unit; they applied lymphatic drainage, intermittent pneumatic compression stockings, and compression bandages and measured usually using echography as well as a suitable heart catheter. The results suggested that there is no contraindication to perform MLD (manual lymphatic drainage) in patients with heart failure when a patient under treatment with MLD for lower limb edema develops heart failure.
A study from Israel investigated seating-induced postural hypotension in older patients with decompensated heart failure; it is a kind of a borderline indication, but the important message is that there is no cardiac decompensation when using compression stockings.
Peptides but no hemodynamic changes mean no risk at all. In stages three and four, multi-layer bandages cause an increase in proper heart pressure without long-term impairment, and lymphatic drainage is no contraindication either. In patients with edema and cardiac insufficiency, the take-home message is that compression therapy should begin with reduced pressure on one lower leg, slowing progressing to more substantial pressure applied to both legs. In stages one and two, there are no restrictions on the kind of compression that can be administered. In stages three and four, comprehensive therapy can be carefully applied to a limited degree if there is a strict indication of clinical and hemodynamic monitoring and if administered in an inpatient setting. We recommend against applying compression in severe cases of cardiac insufficiency stage four; we also discourage the routine application of compression stockings in stage 3 cases; when needed, careful use of compression therapy in this patient group may be entertained if there is a strict indication with clinical and hemodynamic monitoring.
Clinical situations in which compression was previously considered to be contraindicated. In Europe, compression is routinely applied in the event of acute superficial or deep venous thrombosis, but this is not a common practice in all parts of the world. Instead, there is a theory that might promote dislodgment and that it can cause a pulmonary embolism. It should be noted that no evidence does not back this theory up; there is no difference in outcomes between compression and walking or bed rest.