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Causes and treatment of oedema in patients with heart failure

Abstract

Oedema is one of the fundamental features of heart failure, but the pathophysiology of oedema varies. Patients present along a spectrum ranging from acute pulmonary oedema to gross fluid retention and peripheral oedema (anasarca). In patients with pure pulmonary oedema, the problem is one of acute haemodynamic derangement; the patient does not have excess fluid, but pulmonary venous pressure rises such that the rate of fluid transudation into the interstitium of the lung exceeds the capacity of the pulmonary lymphatics to drain away the fluid. Conversely, in patients with peripheral oedema, the problem is one of fluid retention. Understanding the causes of oedema will enable straightforward, correct management of the condition. For patients with acute pulmonary oedema, vasodilatation is important to reduce cardiac filling pressures. For patients with fluid retention, removing the fluid, using either diuretics or mechanical means, is the most important consideration.

Key Points

  • Oedema is one of the fundamental features of heart failure

  • Clinical trial data to guide best practice in managing cardiac oedema are lacking

  • Acute pulmonary oedema is characterized by accumulation of fluid in the air spaces, not by fluid overload

  • Acute pulmonary oedema is best treated as a haemodynamic problem using vasodilators

  • Peripheral oedema is characterized by an excess of total body water

  • Peripheral oedema is best treated by removing fluid, either with diuretics or mechanically

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Figure 1: The Frank–Starling law of the heart.
Figure 2: The correlation between increasing left atrial pressure and the rate of development of pulmonary oedema.
Figure 3: X-ray of the chest of a patient presenting with acute pulmonary oedema.
Figure 4: Schematic representation of possible routes through which vasodilators exert their action.
Figure 5: The right thigh of a patient presenting with fluid retention and pitting oedema.
Figure 6: Pattern of weight loss in a patient presenting with peripheral oedema.
Figure 7: Time course of serum sodium level changes in a patient presenting with oedematous heart failure.

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A. L. Clark declares that he is on the advisory board for Novartis. J. G. F. Cleland declares that he has been a consultant for and received grants from Amgen and Novartis.

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Clark, A., Cleland, J. Causes and treatment of oedema in patients with heart failure. Nat Rev Cardiol 10, 156–170 (2013). https://doi.org/10.1038/nrcardio.2012.191

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