Lymphedema and Sleep Apnea

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Lymphedema and Sleep Apnea

Postby patoco » Sun Jun 11, 2006 9:13 pm


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Should patients who present with bilateral leg edema be screened for
underlying obstructive sleep apnea (OSA)? Yes, suggest the authors of a recent study showing that OSA appears to be common in patients with isolated, unexplained pulmonary hypertension who initially present with bilateral leg edema.[1] The finding supports that of an earlier study, which found a link between bilateral leg edema and isolated pulmonary hypertension.[2]

"The study has important implications for the diagnosis and evaluation of pulmonary hypertension, as well as for the evaluation of leg edema," Robert P. Blankfield, MD, told PULMONARY REVIEWS. "Most cardiologists and pulmonologists do not consider obstructive sleep apnea to be a cause of pulmonary hypertension.

Consequently, OSA is usually not considered in the differential diagnosis of pulmonary hypertension, and sleep studies are typically not ordered when pulmonary hypertension is identified," Dr. Blankfield noted.

"If this study's findings apply to the general population, then OSA may be the most common cause of pulmonary hypertension, at least in patients with leg edema," he said. Furthermore, "failure to consider OSA as a possible cause of pulmonary hypertension and failure to order a polysomnogram might lead physicians to erroneously conclude that a patient's primary diagnosis is pulmonary hypertension, when, in fact, the correct diagnosis may be pulmonary hypertension secondary to OSA," Dr. Blankfield said.

Dr. Blankfield, principal investigator, and his colleagues studied 15 patients ages 41 to 81 years, most of whom were obese and had mild pitting edema. All patients had echocardiographic evidence of pulmonary hypertension (defined as a pulmonary artery pressure of greater than 30 mm Hg), but none of the patients had echocardiographic evidence of left ventricular dysfunction or any clinically apparent pulmonary disease.


OSA, which was present in nine of the 15 patients, was the most common condition associated with bilateral leg edema, followed by systemic hypertension. All six of the hypertensive patients also had OSA.

"Although the majority of studies have found that obstructive sleep apnea does not correlate well with hypertension, this study demonstrated a strong relationship between obstructive sleep apnea and hypertension," said Dr. Blankfield.


Echocardiography may have an important role in the evaluation of leg edema, the authors suggested. "Leg edema in conjunction with an elevated pulmonary artery pressure (greater than 30 mm Hg) should raise suspicion of sleep apnea," said Dr. Blankfield.

"However, in some patients who have leg edema, echocardiography may not allow an estimation of the pulmonary artery pressure. This occurs commonly in obese patients. Consequently, if the echocardiogram is unable to provide an estimation of the pulmonary artery pressure, I suggest referring the patient for a sleep study to check for sleep apnea," he added.

For patients with bilateral pedal edema who lack symptoms of heart failure (such as orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion), the most cost-effective strategy may be to bypass the echocardiogram and refer the patient to a sleep laboratory, Dr. Blankfield said.


Dr. Blankfield believes that edema associated with obstructive sleep apnea is extremely common. "In my primary care practice, I have over two dozen patients who have leg edema who have OSA," he said. "There is nothing unique about my practice. Other primary care physicians who care for adults have similar patients, in similar numbers, most of whom are incorrectly diagnosed as having another condition, typically venous insufficiency, as the cause of their edema. Leg edema associated with OSA is the third most common cardiovascular condition that I see. It is exceeded in frequency by systemic hypertension and coronary artery disease but clearly exceeds strokes and congestive heart failure," said Dr. Blankfield.

"Indeed, it is my opinion that edema associated with OSA represents a
circumstance akin to the discovery that H pylori causes peptic ulcer disease. Just as Heliobacter pylori turned out to be a common infection that went unrecognized for decades, so will edema associated with OSA eventually be recognized as a common condition that long went unrecognized," predicted Dr. Blankfield.

"Unfortunately, almost none of the research literature on PPH [primary pulmonary hypertension] includes sleep studies. As an example, previous studies which identified a relationship between appetite suppressants and PPH did not include sleep evaluations as part of the protocol," he said.

"Obese patients are at risk for OSA, and these individuals use weight loss medications. If the results of our study are generalizable, then the relationship between weight loss medications and PPH is thrown into question," he continued.

Whether obstructive sleep apnea causes pulmonary hypertension remains to be proven. "If one could demonstrate that effectively treating OSA decreases or normalizes pulmonary artery pressure, we could prove that obstructive sleep apnea causes pulmonary hypertension," concluded Dr. Blankfield.

--Deborah L. O'Connor ... edema.html
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