CardiologyTier 1Approach to a presentation

Oedema

Red flags

  • Bilateral leg oedema + orthopnoea/PND + raised JVP - decompensated heart failure, assess for pulmonary oedema
  • Oedema + chest pain/new murmur - consider acute valve lesion (papillary muscle rupture, endocarditis) or pericardial effusion
  • Unilateral leg swelling - do not attribute to heart failure - think DVT
  • Rapidly progressive oedema + hypotension - consider cardiac tamponade or severe RV failure
  • Oedema with cachexia and low BP in known HF - advanced/end-stage disease, consider goals-of-care discussion

Differential by mechanism

Cardiac causes of oedema
  • Right heart failure (any cause) - secondary to LV failure, pulmonary hypertension, cor pulmonale, or isolated RV disease (ARVC, RV infarct)
  • Constrictive pericarditis - oedema/ascites out of proportion to dyspnoea, Kussmaul's sign
  • Tricuspid regurgitation - primary (endocarditis, carcinoid, rheumatic) or secondary to RV/pulmonary pressure overload
  • Cardiac tamponade - JVP raised, pulsus paradoxus, muffled heart sounds
Mimics to exclude before assuming cardiac
  • Venous insufficiency/DVT (usually asymmetric)
  • Hypoalbuminaemia (nephrotic syndrome, cirrhosis, malnutrition) - JVP typically normal/low, distinguishes from cardiac
  • CCB-induced peripheral oedema - common, mistaken for heart failure, JVP normal
  • Hypothyroidism, lymphoedema

Focused history

  • Onset and progression, symmetry
  • Orthopnoea, PND, exertional dyspnoea, weight gain
  • Chest pain, palpitations, syncope
  • Known cardiac diagnosis (prior MI, valve disease, cardiomyopathy), adherence to HF medications and fluid/salt restriction
  • Medication review - CCBs, NSAIDs, corticosteroids as non-cardiac contributors
  • Alcohol history (cardiomyopathy, liver disease)

Focused examination

  • JVP - the key discriminator; raised in cardiac causes, normal/low in hypoalbuminaemic causes
  • Pitting oedema extent (ankle to sacrum - track daily), hepatomegaly, ascites
  • Auscultation - S3 (volume overload), murmurs (TR - pansystolic at lower left sternal edge, inc with inspiration), pericardial knock
  • Pulsus paradoxus, Kussmaul's sign if tamponade/constriction suspected
  • Peripheral perfusion, pulses

Investigation strategy

  • BNP/NT-proBNP - supports/refutes a cardiac cause, but note reduced by obesity and raised by renal impairment/AF/age
  • ECG - arrhythmia, prior infarct, low voltage (consider pericardial effusion/infiltrative disease)
  • Echocardiogram - LV/RV function, valve disease, pericardial disease, pulmonary artery pressure estimate
  • UEC, LFT + albumin, TFT, urinalysis (proteinuria) - to exclude non-cardiac causes
  • CXR - cardiomegaly, pulmonary congestion, effusion

Management

Treat the underlying cardiac cause
  • Decompensated heart failure - loop diuretic titrated to congestion, treat precipitant (arrhythmia, ischaemia, non-adherence, infection), optimise GDMT once stable
  • Constrictive pericarditis - diuretics for symptom control; pericardiectomy if refractory/confirmed
  • Significant TR - treat underlying pulmonary hypertension/LV disease; valve intervention if primary/severe and symptomatic
  • Tamponade - urgent pericardiocentesis
General measures
  • Daily weight, salt restriction, fluid restriction if hyponatraemic/severe
  • Review and stop/reduce non-cardiac contributors (CCB, NSAID) where safe
  • Diuretic resistance - check adherence/timing, add a thiazide for sequential nephron blockade, consider IV diuretic if gut oedema impairs absorption

Traps

  • Treating unilateral leg swelling as heart failure - always exclude DVT/local cause
  • Attributing CCB-induced oedema to worsening heart failure and escalating diuretics unnecessarily - check the JVP and medication list first
  • Relying on BNP alone without echo - a modestly elevated BNP does not confirm the mechanism
  • Missing constrictive pericarditis in a patient with oedema/ascites but relatively preserved LV function and unremarkable initial echo - needs specific imaging signs sought
  • Aggressive diuresis in tamponade/severe RV failure with preload dependence - can precipitate hypotension

Talk track

1. JVP separates cardiac from hypoalbuminaemic oedema

  • "A raised JVP points me toward the heart; a normal JVP points me toward albumin, the liver, or a drug."

2. Symmetry matters

  • "Unilateral swelling is a DVT work-up, not a heart failure work-up."

3. Echo confirms the mechanism

  • "BNP screens; the echocardiogram tells me whether it's LV failure, valve disease, or the pericardium."

4. Check the medication list before escalating diuretics

  • "A calcium channel blocker is a common, reversible cause that gets mistaken for worsening heart failure."

5. Treat the cause, not just the fluid

  • "Diuretics manage the symptom; the underlying valve or pericardial disease is what actually needs fixing."

8 of 8 sections written · drafted 2026-09-13