What could be causing heavy legs in an older adult with a history of cardiovascular disease?

Heavy Legs in Older Adults with Cardiovascular Disease

Most Likely Causes

In an older adult with cardiovascular disease presenting with heavy legs, you should prioritize evaluation for peripheral arterial disease (PAD), chronic venous insufficiency, and heart failure—these are the three most common vascular causes in this population. 1, 2

Peripheral Arterial Disease (PAD)

• PAD is extremely common in patients with existing cardiovascular disease, with the coprevalence of coronary and peripheral arterial disease being well-established 1
• The sensation of heavy legs represents atypical leg pain, which is actually more common than classic intermittent claudication in PAD patients 1, 3
• In the PARTNERS survey, among patients with PAD: only 6-13% had typical claudication, while 46-62% had atypical leg pain, and 26-48% were classified as "asymptomatic" 1
• However, "asymptomatic" PAD patients still have significant functional impairment—they often cannot walk enough to reveal symptoms due to comorbidities like heart failure or reduced pain sensitivity from diabetic neuropathy 1, 3

Key physical examination findings to assess:

• Palpate femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally; grade intensity as 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding) 1
• Absence of both dorsalis pedis and posterior tibial pulses strongly suggests PAD 4
• Remove shoes and socks to inspect feet for color, temperature, skin integrity, distal hair loss, trophic skin changes, and hypertrophic nails 1
• Auscultate femoral arteries for bruits 1

Diagnostic confirmation:

• Measure ankle-brachial index (ABI) in both legs—this is the first-line diagnostic test 1
• ABI <0.90 confirms PAD diagnosis 1
• If ABI is normal (0.91-1.30) but clinical suspicion remains high, perform exercise ABI testing 1
• If ABI >1.40 (suggesting medial calcification, common in diabetes), measure toe-brachial index or obtain duplex ultrasound 1

Chronic Venous Insufficiency

• This is the most common localized cause of heavy legs in older patients 2, 5
• Characterized by peripheral edema that worsens in the evening and improves with leg elevation 2
• Look for hyperpigmentation, lipodermatosclerosis, and trophic skin changes on examination 1, 2
• Critical: Never apply compression therapy without first checking ABI to exclude PAD—compression is contraindicated if significant arterial disease is present 2

Heart Failure

• Right heart failure and biventricular failure cause increased central venous hypertension, leading to bilateral lower extremity edema 2
• Heart failure with preserved ejection fraction is increasingly common in patients with hypertension and diabetes 2
• Obtain BNP or NT-proBNP levels if heart failure is suspected; if elevated or clinical suspicion is high, perform echocardiography 2

Additional Systemic Causes to Consider

Medication-Induced Edema

• Calcium channel blockers are the most common medication cause of bilateral leg edema in hypertensive patients 2
• Review all medications for potential edema-causing agents 5, 6

Metabolic and Endocrine Disorders

• Kidney disorders cause protein loss and sodium/water retention 2
• Liver cirrhosis decreases protein synthesis, leading to decreased plasma oncotic pressure 2
• Thyroid and adrenal disorders cause abnormal water excretion 2
• Check complete blood count, urinalysis, electrolytes, creatinine, blood glucose, thyroid-stimulating hormone, and albumin 5

Pulmonary Hypertension and Sleep Apnea

• Obstructive sleep apnea increases pulmonary vascular resistance and pulmonary hypertension, which can cause leg edema 2, 5
• Evaluate patients with daytime somnolence, loud snoring, or neck circumference >17 inches with echocardiography 5

Critical Pitfalls to Avoid

The "Masked LEAD" Phenomenon

• One-third of patients labeled "asymptomatic" actually cannot walk more than six blocks due to comorbidities—they are at high risk for both cardiovascular events and limb events 1
• These patients are typically older, more often women, with higher rates of neuropathy and multiple comorbidities 1
• They may present suddenly with severe complications like toe necrosis after trivial trauma 1

Coexistent Arterial and Venous Disease

• Patients with cardiovascular disease frequently have both PAD and venous insufficiency simultaneously 2
• Always assess arterial perfusion before treating presumed venous disease 2

Distinguishing PAD from Pseudoclaudication

The following features help differentiate vascular claudication from other causes 1:

• Lumbar spinal stenosis: pain improves with forward flexion, worse going downhill
• Venous claudication: pain persists after stopping, improves with leg elevation
• Osteoarthritis: pain related to joint use, not consistently related to walking distance
• PAD claudication: reproducible walking distance, rapid relief with rest (typically <5 minutes), worse going uphill

Immediate Management Priorities

For Suspected PAD

• Initiate cardiovascular risk reduction immediately: antiplatelet therapy, statin therapy, blood pressure control, smoking cessation 1
• All PAD patients should be treated as "high-risk" equivalent to coronary artery disease 1
• Refer to vascular specialist if ABI <0.40 (high risk for critical limb ischemia) or if diabetic with any PAD 1

For Suspected Critical Limb Ischemia

• Any patient with rest pain, non-healing wounds, or tissue loss requires expedited vascular evaluation 1
• Patients at risk for critical limb ischemia (ABI <0.4 in non-diabetics, or any diabetic with PAD) should undergo regular foot inspection 1
• Initiate systemic antibiotics promptly if skin ulceration with signs of infection is present 1

For Venous Insufficiency

• Treat with leg elevation and compression stockings (30-40 mmHg) only after confirming adequate arterial perfusion 2
• Consider diuretics for symptomatic relief 5

Follow-Up and Surveillance

• Patients with PAD and cardiovascular disease require close monitoring due to high risk of cardiovascular events (MI, stroke) and limb complications 1
• Provide verbal and written instructions for daily foot inspection and self-surveillance 1
• Schedule regular follow-up with appropriate specialists based on findings 1