Oedema secondary to CCB

Question 1

A 53 year old female takes amlodipine for HTN, and presents because her ankles are swollen. Her BP is 154/76 mmHg in your office, similar to home BP measurements. How would you manage this situation?

Answer 1

Impression
Bilateral lower limb oedema has a number of importantt causes. Given the amlodipine use, CCBs are known to cause the A/E of swelling in a proportion (10-12%).

Causes of bilateral lower-limb oedema

• CHF
• renal failure
• nephrotic syndrome
• liver failure
• protein losing enteropathy

Goals of Mx

• Conduct targeted assessment, screening for other red flag causes of bilateral LL oedema
• Cease or reduce dose of CB
• escalate current HTN management, likely to dual therapy and optimise dosing whilst mitigating any other CVD risk factors both pharmacologically and non-pharmacologically, consider admission for management of HTN if evidence of end-organ damage. Avoid diuresis given patients are not volume overloaded.

Question 2

HTN - History

Answer 2

History

• PC: temporal relationship to swelling and amlodipine starting, dose of amlodipine, how long oedema for, worsening/improving?
• Sx of HTN: temporal headache, visual change, frothy urine, abdo pain, N/V.
• REDS: chest pain, dry cough, dyspnoea/WOB, orthopnoea
• PMHx, cardio disease, renal disease, anything run in family?
• CVD risk factors: smoking, alcohol, obesity, sedentary,
• Meds, allergies

Question 3

HTN - Examination

Answer 3

Examination

• General appearance + vitals
• Cardiorespiratory: ?APO, sacral oedema, heart sounds
• Peripheral vascular exam
• Hydration status
• Fundoscopy
• Cranial nerves exam

Question 4

HTN - Investigations

Answer 4

Investigations

• bedside: uACR, urinalysis
• Bloods: UEC, LFT, FBC, CVD baselines (consider further Ix if ?secondaries such as plasma free metanephrines)
• Imaging: nil at this stage unless concerned re Cardio pathology, perhaps CXR is evidence of pulmonary oedema

Question 5

HTN - Management

Answer 5

Management
Supportive
- appropriate lifestyle changes
- elevate legs
- GP referral and safety-netting/ review period

Definitive
Swelling
- Cease CCB, consider switching anti-HTN agent
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