“Get to know your patients!”

At the “27th European Vascular Course” held in Maastricht in spring of 2024, Dr. med. Tobias Hirsch explained why cardiac insufficiency, peripheral arterial disease and polyneuropathy should not necessarily preclude compression therapy.

Many patients with vein problems who can be helped with compression therapy also suffer from other serious conditions, such as cardiac insufficiency, peripheral arterial disease (PAD) or polyneuropathy, which are generally regarded as contraindications. But when should you actually advise against compression? And: how can this be successfully determined in practice? These were questions included in a workshop organized by Dr. med. Tobias Hirsch, Specialist in Internal Medicine, Angiology and Phlebology from Halle an der Saale, Germany, at the “27th European Vascular Course” in Maastricht in 2024.

Cardiac insufficiency: the NYHA stages are decisive

According to Dr. Tobias Hirsch, the assessment of the degree of heart failure should be based on the stage categorization developed by New York Heart Association. They range from I to IV. For patients in stage I (asymptomatic heart failure) and stage II (mild cardiac insufficiency when subjected to strain), heart failure is no contraindication when it comes to compression.

Only in stage III (shortness of breath when subjected to mild strain) and stage IV (shortness of breath at rest), i.e. in cases of severe heart failure, is compression therapy contraindicated.

Causes include serious conditions, such as coronary heart disease (CHD), atrial fibrillation and cardiac decompensation. “If the patient is also suffering from lymphedema that must be treated with lymphatic drainage and compression therapy, we first have to find out whether the patient is suffering from dyspnea, nocturia, fatigue, angina pectoris or general weakness,” explains Dr. Tobias Hirsch. Shortness of breath (dyspnea) in particular is a potentially life-threatening complication. The reason being: by mobilizing the edema fluid, compression or lymphatic drainage can cause the additional volume to strain the heart.

In order to assess the risk, the specialist asks his patients whether they suffer from breathlessness even without excessive strain, if they can sleep lying flat, what medication they are taking, and not least, whether they were able to tolerate manual lymphatic drainage and compression stockings in the past. In this case, treatment can generally be continued. In addition to examination with a stethoscope to exclude water in the lungs, NT-proBNP (brain natriuretic peptide) can serve as a suitable biomarker. Elevated NT-proBNP levels are usually a sign of excessive strain on the heart muscle and indicate decompensated heart failure (NYHA Stages III and IV). As opposed to lymphedema, edema caused by cardiac heart failure also occurs symmetrically in both legs.

PAD: the ankle-brachial index offers key insights

In cases of peripheral arterial disease (PAD), compression therapy is generally possible, too, according to Dr. Tobias Hirsch. A prerequisite is monitoring arterial blood flow. “Initially, you can just manually check the foot pulse if the case history indicates impaired arterial circulation,” suggests the vascular specialist. If no foot pulse can be palpated, the ABI (ankle-brachial index) value provides insights about the extent of the impaired blood flow. It can easily be measured using a Doppler ultrasound scanner. If the ABI value is below 0.9, you have to check for skin changes. However, compression stockings are only contraindicated at a value below 0.6 or an absolute value of the ankle blood pressure of 60 mmHg when lying down. Intermittent pneumatic compression (IPC) may still be possible, because it takes place when at rest. IPC can also be considered to treat the PAD.

Polyneuropathy: three simple tests provide clarity

As the last example for a potential risk relating to compression therapy, Dr. Tobias Hirsch mentioned polyneuropathy, which particularly affects patients with diabetic foot syndrome. The problem is that “they can’t feel pressure or pain in the foot during compression, for example caused by folds.” This can result in abnormalities or injuries in the skin. Dr. Tobias Hirsch introduced three simple and inexpensive tests that are carried out in the foot area or lower leg to find out whether the patient has neuropathy and determine its severity: temperature sensation can be determined using a device with one plastic end and one end made of metal. On skin contact, the materials are perceived as having different temperatures. A Rydel-Seiffer tuning fork, which the physician strikes gently, provides information about vibration perception. A device featuring a nylon filament helps determine how a patient responds to pressure and touch. In cases of severe polyneuropathy, the vascular experts advises against high continuous compression. In these cases, the compression garment has to be made to fit perfectly, and padding may have to be integrated.

The most important thing: listening to your patients

Dr. Tobias Hirsch’s personal conclusion: heart failure, PAD and polyneuropathy do not necessarily have to be contraindications. It really depends on the severity of the condition in each individual case. “Get to know your patients,” he said appealing to the participants of his workshop. In addition to using hands and eyes during the examination, the ears are also important for the diagnosis: “We will find out the most relevant aspects when patients tell us their story.”

Images: Bauerfeind, Anika Büssemeier