Initial Workup for Anasarca

Immediate Assessment

Evaluate for signs of hemodynamic instability including hypotension, tachycardia, abnormal respiratory effort, and low oxygen saturation in patients with anasarca, as recommended by the European Society of Cardiology 1, 2
Assess for signs of hypoperfusion: cold extremities, oliguria, mental confusion, dizziness, and narrow pulse pressure in patients with suspected cardiac causes of anasarca 2
Check for bilateral pulmonary rales, orthopnea, and paroxysmal nocturnal dyspnea which suggest left-sided heart failure in patients with anasarca 2
Examine jugular venous pressure (JVP) as elevated JVP improves the specificity of edema as a sign of congestion in patients with suspected heart failure 3

Complete blood count to assess for anemia which may exacerbate heart failure in patients with anasarca, as recommended by the European Heart Journal 4
Comprehensive metabolic panel including electrolytes, blood urea nitrogen (BUN) and creatinine to assess renal function, and liver function tests to evaluate for hepatic causes of anasarca 3, 4
Cardiac biomarkers, such as natriuretic peptides (BNP or NT-proBNP) and cardiac troponins, to help differentiate cardiac from non-cardiac causes of dyspnea in patients with anasarca 4
Thyroid stimulating hormone (TSH) to rule out thyroid dysfunction in patients with anasarca 4
Urinalysis with microscopic examination and quantification of proteinuria to assess renal involvement in patients with anasarca, although this specific guideline is from the Kidney International journal, it is relevant to the assessment of renal causes 6

Chest X-ray to assess for interstitial or alveolar edema, and alternative non-cardiac causes (e.g., pneumonia) in patients with anasarca, as recommended by the European Heart Journal 1, 3, 4
12-lead ECG to identify arrhythmias, ischemia, or conduction abnormalities in patients with suspected cardiac causes of anasarca 4
Echocardiography within 48 hours to assess left and right ventricular function, valvular abnormalities, and pericardial disease in patients with anasarca, as recommended by the European Society of Cardiology 1, 3, 4

Cardiac causes - Look for history of coronary artery disease, hypertension, or valvular disease, elevated BNP/NT-proBNP, and reduced ejection fraction on echocardiography in patients with anasarca, as recommended by the European Heart Journal 1, 2, 3, 4
Renal causes - Look for elevated creatinine and BUN, abnormal urinalysis with proteinuria, and history of kidney disease or recent acute kidney injury in patients with anasarca, as recommended by the Kidney International journal and the European Journal of Heart Failure 3, 4, 6
Hepatic causes - Look for elevated liver enzymes, and history of alcohol use or viral hepatitis in patients with anasarca, as recommended by the European Heart Journal 4

Failing to measure body weight consistently, and overlooking non-cardiac causes of anasarca, as warned by the European Journal of Heart Failure 3
Delaying echocardiography, which should be performed within 48 hours in patients with unknown cardiac function, as recommended by the European Heart Journal 7
Inadequate assessment of volume status, which should include both clinical examination and laboratory parameters, as recommended by the European Journal of Heart Failure 3

In patients with profound anasarca, more aggressive fluid removal may be required compared to those with milder edema, as suggested by the European Journal of Heart Failure 3