Risks and complications of compression therapy
Dr Tobias Hirsch presented topics about oedema drainage and cardiac insufficiency as well borderline indications.
Dr. Tobias Hirsch started his presentation with a video of a female diver, he stated that at 20-25 meters under the water, the body is being under pressure of 1500 mmHG and that is the normal for a healthy individual.
He presented a case study, a patient called Ottilie, a-75-year-old woman, suffers from coronary heart disease (CHD), atrial fibrillation, heart failure NYHA stage II and lymphoedema in her right leg. I wonder if she could receive compression therapy and edema drainage despite her heart insufficiency.
He then mentioned the causes of heart failure are
- Hypertensive heart disease
- Heart valve defect
- Cardiac arrhythmia
And those who are affected from heart failure struggle with
- General weakness/fatigue
- Angina pectoris
- Bilateral edema
Dyspnea, which is shortness of breath, is the most critical symptom as it is potentially life threatening. Heart failure degrees of severity are classified into 4 stages:
Stage I: no limitations, no symptoms under normal activity.
Stage II: slight limitation but there are symptoms begin to show in ordinary activity.
Stage III: cardiac decompensation starts at grade three while patients are comfortable at rest.
Stage IV: patients are not able to carry on activity, they have symptoms at rest.
When is it imperative to stop decongestive therapy?
Showing the role of compression play through compression homunculus. It illustrates how compression treats edema in the leg but in worst case, the water which was inside the leg causes pulmonary edema.
A study, in 1978, observed the redistribution of blood volume, by applying 25-40 mmHG compression using kind of inflatable rubber boot, they found that the blood volume of the leg decreases by 33.4/ - 38% depending on pressure but the extension of the blood organ of the visceral organs was 6-7%
In another study, it used air plethysmography to determine there is volume displacement of about 40 mL per leg when below knee class one or two medical compression stockings are worn.
Only a fraction of the blood reaches the right heart because of the elastic properties of the inferior vena cava (IVC) and heart rate (HR) changes adjusts the cardiac output to compensate for the increased load.
The European guidelines published a list of factors that decompensate heart insufficiency. In this list, compression and lymphatic drainage are not included.
Returning to Ottilie, are we allowed to decongest her?
It is in one’s hands. One should assess the risk as medical history as what medications do you take, if you’re suffering from dyspnea and breathlessness, if you’re sleeping in a flat position and whether you tolerate medical lymphatic drainage (MLD) and medical compression stockings (MCS). In addition to that, you should examine yourself from such as bilateral edema as it is typical for heart failure. Another method is to use a biomarker called NT-proBNP which is a biomarker for the progress of heart insufficiency, marker for myocardial wall stress and emitted by the atria and ventricular myocardium. Normal values rule out relevant heart failure.
A German review in 2017 shows limit values of NT-proBNP and it depends also on patient’s age.
And that’s how Ottilie was treated.
Because of the less data about biomarkers, he mentioned a review, which was published in 1996, used hANP (Human Atrial Natriuretic Peptide), which is related to BNP and anti-probing. The marker showed a brief increase of hANP in NYHA stage II, but all patients indicated a stable hemodynamics and cardiac function. Moreover, they included that compression therapy is considered harmless in patients with cardiac insufficiency (NYHA II).
In another paper from Belgium, they investigated NYHA III and IV patients. They applied lymphatic drainage, intermittent pneumatic compression, compression stockings and compression bandages. They measured using echography and right heart catheter. They concluded that these patients would possibly use lymphatic drainage. But to be noted, they only treated the right limb.
And a paper from Israel, they overall concluded that no cardiac decompensation at all when using compression stockings.
A case report then suggests that compression stockings should be used with caution in patients with limited cardiac reserve.
In conclusion, if stage II patients are treated using medical compression stockings, we see a temporary increase in natriuretic peptides, but no hemodynamic changes which mean no risk at all.
In stages III and IV, multi-layer bandages cause an increase of right heart pressure without long-term impairment and lymphatic drainage is no contraindication.
Patients with edema and cardiac insufficiency: it is recommended to start compression therapy with reduced pressure on one lower leg and slowly progress to stronger pressure applied on both legs.
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.
A theory promotes that using compression might promote dislodgement of clots and cause pulmonary embolism. It is just a theory with no evidence. Compression is the most effective treatment to reduce edema in mobile patients. In the case of superficial veins, we observe faster thrombus regression with heparin and compression therapy. In previous concepts compression is not contraindicated in acute thrombotic events but results in favorable clinical outcomes when applied with caution. Proper compression leads to immediate improvement of pain and edema.
In case of inflammatory diseases and infections, erysipelas and cellulitis were considered contraindications to compression therapy due to risk of circulating bacteria, but they may provide synergistic effects and antibiotic treatment by reducing inflammation, improving lymphatic outflow, and decreasing swelling.
We suggest additional compression in purpura due to leukocytoclastic vasculitis and in leg erysipelas or cellulitis to reduce inflammation, pain, and edema. In infection inflammation, we suggest only in combination with antibacterial treatment.