Evaluation and Management of Bilateral Ankle Edema

Initial Laboratory Evaluation

Ankle-brachial index (ABI) measurement is recommended, with a normal ABI ranging from 0.90-1.40, and an abnormal low ABI being <0.90, and an abnormal high ABI being >1.40, which suggests calcified vessels, as recommended by the European Heart Journal 1
For patients with suspected venous insufficiency, D-dimer testing is recommended if acute onset with risk factors for DVT, and compression ultrasonography if DVT is suspected, as recommended by the American College of Chest Physicians 2
Assessing kidney dysfunction with BUN, creatinine, and urinalysis for proteinuria is suggested, as recommended by the American Journal of Kidney Diseases 3
Initial laboratory evaluation for suspected hemoconcentration should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose, lipid profile, liver function tests, and thyroid-stimulating hormone, as recommended by the American Heart Association 4, 5

Evaluating heart failure with BNP/NT-proBNP and echocardiography is recommended, as suggested by the American College of Cardiology, and the European Heart Journal provides guidance on ABI measurement which can be related to heart failure diagnosis 1
Looking for hemosiderin deposition and skin changes to diagnose venous insufficiency is suggested, as recommended by the American College of Phlebology, and the American College of Chest Physicians provides guidance on D-dimer testing and compression ultrasonography for DVT diagnosis 2
Orthostatic blood pressure changes should be measured to assess volume status in patients with suspected hemoconcentration, as recommended by the American Heart Association 4, 5

A thorough medication review is necessary before extensive workup, as certain medications such as antihypertensives, anti-inflammatory drugs, and hormonal therapies can contribute to edema 4, 5, 6, 7, 8
Failing to consider medication side effects as potential causes of edema can lead to misdiagnosis, and overlooking multifactorial causes, particularly in older adults where edema is often due to multiple contributing factors, can lead to inadequate treatment 4, 5, 6, 7, 8

Isotonic saline (0.9% NaCl) infusion at 15-20 ml/kg body weight/hour during the first hour in the absence of cardiac compromise is recommended for volume repletion, as recommended by the American Diabetes Association 6
Appropriate heart failure therapy should be administered for heart failure-related hemoconcentration, as recommended by the American Heart Association 4, 7
Serial assessment of hemoconcentration parameters (hemoglobin, hematocrit, total protein, albumin) and monitoring of vital signs, including orthostatic measurements, should be performed to monitor response to treatment, as recommended by the American Diabetes Association 6
In severe cases, more intensive monitoring may be required, including central venous pressure measurement in appropriate clinical settings, as recommended by the American Heart Association 8