From the Guidelines
The next step for this patient with increased leg swelling, given their history of diabetes, hypertension, dyslipidemia, sleep apnea, and moderate mitral annular calcification, should be a comprehensive evaluation including a physical examination, laboratory tests, and possibly imaging studies. The patient's presentation with leg swelling as their primary symptom suggests a potential syndrome of fluid retention, which may be indicative of heart failure 1. A careful history of current use of alcohol, tobacco, illicit drugs, “alternative therapies,” and chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with potential heart failure 1.
The evaluation should start with a physical examination to assess the extent and characteristics of the edema, check vital signs including blood pressure, and perform a cardiac examination to evaluate for signs of heart failure. Laboratory tests should include a basic metabolic panel to assess kidney function, BNP or NT-proBNP to evaluate for heart failure, although the value of serial measurements of BNP to guide therapy for patients with HF is not well established 1, and possibly albumin levels to check for hypoproteinemia.
A Doppler ultrasound of the lower extremities would be appropriate to rule out deep vein thrombosis, which can present with unilateral or bilateral leg swelling. Additionally, a repeat echocardiogram should be considered to reassess cardiac function and the status of the mitral valve, as the previous echo from 2022 showed moderate mitral annular calcification which could have progressed and may be contributing to the patient's symptoms 1.
Treatment will depend on the underlying cause but may include diuretics such as furosemide 20-40mg daily if fluid overload is present, optimization of diabetes and hypertension management, and possibly compression stockings for venous insufficiency if identified. The NYHA functional classification may be used to quantify the degree of functional limitation imposed by HF, but its limitations should be considered 1.
Key considerations in the management of this patient include:
- Assessing volume status and weight at each visit 1
- Obtaining a careful history of current use of substances and therapies 1
- Using formal tests of exercise tolerance, such as measurement of the distance that a patient can walk in 6 minutes, to assess the level of functional impairment 1
- Considering maximal exercise testing, with measurement of peak oxygen uptake, to identify appropriate candidates for cardiac transplantation or to determine disability 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Assessment
The patient has a history of diabetes, hypertension, dyslipidemia, sleep apnea, and moderate mitral annular calcification. The patient's current presentation of increased leg swelling requires further evaluation.
Laboratory Tests
The following laboratory tests may be useful in assessing the patient's condition:
- Complete Blood Count (CBC) to evaluate the patient's blood cell components, including red blood cell count, hemoglobin, hematocrit, and white blood cell count with differential 2, 3, 4, 5
- Basic Metabolic Panel (BMP) to assess electrolytes, blood urea nitrogen, and creatinine, which can reflect renal function and acid-base homeostasis 6
Next Steps
Based on the patient's history and current presentation, the next steps may include:
- Ordering a CBC and BMP to evaluate the patient's blood cell components and renal function
- Assessing the patient's leg swelling and determining the underlying cause, which may be related to cardiovascular or metabolic diseases
- Considering the patient's history of mitral annular calcification and its potential impact on cardiac function
- Developing a plan of care based on the laboratory results and physical examination findings, which may involve monitoring the patient's condition, adjusting medications, or referring the patient to a specialist 3