Intended for healthcare professionals

Practice 10-Minute Consultation

Managing heart failure related peripheral oedema in primary care

BMJ 2020; 369 doi: (Published 22 June 2020) Cite this as: BMJ 2020;369:m2099
  1. Daniel Bromage, specialty trainee in heart failure1,
  2. Joseph Mayhew, general practitioner, clinical lead23,
  3. Daniel Sado, honorary senior lecturer and consultant in heart failure4
  1. 1King’s College London British Heart Foundation Centre of Excellence, London, UK
  2. 2Nexus, Surrey Docks Health Centre, London, UK
  3. 3Clinical Effectiveness, London, UK
  4. 4Department of Cardiology, King’s College London, London, UK
  1. Correspondence to dan.bromage{at}

What you need to know

  • Always consider reasons for decompensation in heart failure, as they may require specific treatment

  • After addressing the cause of decompensation, increasing oral diuretics at an early stage is the best way to prevent the need for hospital admission

  • Worsening renal function (up to 25% increase in creatinine or a 20% drop in eGFR) may be an acceptable impact of diuretic therapy in decompensated heart failure and should not necessarily prompt diuretic cessation

You consult with a 78 year old woman. She reports increased ankle swelling and has longstanding heart failure with reduced ejection fraction (measured as 25% on her most recent echocardiogram) because of previous myocardial infarction. She is known to local heart failure services.

Heart failure is a clinical syndrome caused by a structural or functional cardiac abnormality. It is characterised by reduced cardiac output or elevated intracardiac pressures, which can result in inadequate tissue perfusion. Heart failure affects approximately 900 000 patients in the UK.1 If a patient who was hitherto stable deteriorates, this is referred to as “decompensated” heart failure, and may manifest as pulmonary or peripheral oedema. This article provides an approach for primary care physicians to managing peripheral oedema in people known to have heart failure in the community. The article includes a recap of the best available evidence.

What you should cover

What questions should you ask?

History, examination, and investigations should aim to establish the cause of the peripheral oedema, which is most likely to be decompensated heart failure in this case. Note the impact of the symptoms, which can be distressing. Shoes and clothing may no longer fit, and as the swelling worsens, some patients describe feeling like their skin is about to burst. Box 1 gives the most common differential diagnoses for peripheral oedema.

Box 1

Common differentials of peripheral oedema

  • Heart failure

  • Medications, including calcium channel antagonists, alpha blockers, hydralazine, testosterone

  • Chronic kidney disease

  • Hypoalbuminaemia

  • Chronic …

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