Pacemaker, swollen ankles

[Snowyowl01]

Hi, just wondering if anyone has had this problem. I had PM fitted Aug21 and AV node ablation 4 months ago. Bp been raised so on meds for that, but my ankles started swelling couple months ago. Gp just gave me water tablets says not the bp meds. But ankles still swelling 5 days later.

[baba]

What BP meds are you taking - some are known to cause ankle swelling in some people.

[Snowyowl01]

Hi, yes I did ask Gp if could be the cause but said no.I take Irbesartan and because bp was a bit high this week Gp has given me Lercanidipine to take as well. xx

[Lilou1952 in reply to Snowyowl01]

Lercanidipine is a calcium channel blocker and notorious for causing peripheral oedema, including ankle oedema

A recognised adverse effect of the calcium channel blocking agents (CCBs) which may limit their usefulness

particularly in an aging population who are more likely to have co-morbidities

ankle oedema can range from being mild and unnoticed to severely affecting quality of life

risk of developing ankle oedema whilst using CCB therapy appears to be higher in:

women, older patients,

those with heart failure,

upright postures, and

those in warm environments.

Giving you a diuretic to correct a side effect of a CCB is not the best medicine.

[Snowyowl01 in reply to Lilou1952]

Thank you for this great reply, I had the ankle swelling before I started the Lercanidipine though. Hopefully the blood test my show up any problems. I will contact GP then. x

[Lilou1952 in reply to Snowyowl01]

Giving a CCB to someone who already has peripheral oedema does not make sense. I will give you a lengthy direct quote below."Mechanism of ankle oedema

mechanisms by which CCBs give rise to ankle oedema are not currently understood

proposed mechanisms include an increase in capillary pressure, resulting in fluid loss from the capillaries, or by interference with local vascular control

unlike peripheral oedema caused by fluid retention, CCB-induced oedema appears to be due to redistribution of fluid from capillaries to interstitial spaces

oedema caused by CCBs seems unaffected by diuretic treatment, suggesting it may be due to fluid pooling rather than fluid retention

oedema occurs despite CCBs possessing inherent diuretic effects

as well as these possible mechanisms, CCB therapy blocks reflex increases in precapillary resistance which occur on standing, further compounding the problem of oedema formation

evidence suggests that ankle oedema may have a delayed onset, with its incidence increasing gradually as treatment continues, meaning it is not likely to be a transient, self-limiting effect (2)

Difference in chemical class

CCBs are generally classified into dihydropyridines (DHP) and non-dihydropyridines (diltiazem, verapamil) based on their chemical structure

with oedema being more likely with the dihydropyridine agents

(DHP) (amlodipine, nifedipine, felodipine, nimodipine, nicardipine, lercanidipine, lacidipine)

incidence of ankle oedema has been reported as ranging from 1-15% in patients treated with DHP agents

within the DHP group, it is thought that those which are more lipophilic, thus stay at the site of action for longer (such as lercanidipine and lacidipine), may be associated with a lower incidence of ankle oedema

ankle oedema incidence appears to be dose related

ankle oedema seems to be associated with both long and short acting DHP agent use

non DHP agents

rate of ankle oedema occurring with verapamil therapy is variable

increases plasma volume whilst also reducing vasoconstriction in the lower extremities, similar to amlodipine and nifedipine

suggested that reduced incidence of ankle oedema in patients treated with diltiazem compared to other CCB agents (3)

Management of ankle oedema with CCBs

Ankle oedema is usually refractory to diuretic treatment as it is due to changes in capillary pressure leading to leakage into interstitial areas, rather than due to water retention.

Treatment strategies include (4):

Non-pharmacological interventions

little evidence to suggest these methods may be effective in reducing oedema

- these interventions include elevation of legs when in a prone position, or graduated compression stockings, may be an option in some patients with mild oedema

Dosage adjustments

as dose related side effect - reduction of dose may lead to resolution/improvement

- however note that the relationship with ankle oedema and CCB use may not occur in an exact dose-proportional relationship (1)

Switching to an alternative CCB

switching between classes e.g DHP to non DHP CCB; or within the same class e.g. a third generation DHP, such a lercanidipine, with a lower reported incidence of ankle oedema may also be an option

Adding an ACEi or ARB

evidence that adding an ACEi to a CCB reduces the incidence of ankle oedema. The mechanism by which this occurs is not currently known (4)

mechanisms by which ARBs reduce incidence of CCB induced ankle oedema remains unknown, but are likely to be similar to that involved when an ACEi is added to CCB therapy

Adding a nitrate

due to their venodilating action, may be offer some useful effects in treating CCB induced ankle oedema, but their use are limited by the practical considerations of having a stop-start regimen so tolerance does not develop (4)

Discontinuation of CCB

Reference:

NHS Specialist Pharmacy Service (March 2020). What are the reported incidences of ankle oedema with different calcium channel blockers?

Zanchetti A. Emerging data on calcium channel blockers: The COHORT study. Clinical Cardiology. 2003; 26(sII): II-17- II-20.

Sirker A, Missouris CG, and Macgregor G. Dihydropyridine calcium channel blockers and peripheral side effects. Journal of Human Hypertension. 2001: 15; 745-746.

NHS Specialist Pharmacy Service (March 2020). How should ankle oedema caused by calcium channel blockers be treated?

Last edited 05/2020"

[Snowyowl01 in reply to Lilou1952]

Wow, thank you for this info again. I will speak to Gp again, she only gave me weeks supply of furosemide. Not sure what I need to say though as bp seems to be settling on Irbesartan 150mg and 10mg Lercanidipine. Do you think I should ask for other meds if swelling doesnt improve? thank you for your help x

[Lilou1952 in reply to Snowyowl01]

Probably the most important thing first is the blood test BNP (suggest you google info on that). But then get off the CCB.

[Snowyowl01 in reply to Lilou1952]

Thank you x

[Lilou1952 in reply to Snowyowl01]

The diuretic will lower your blood pressure but you might be better swapping from a loop diuretic to a thiazide when you drop the CCB.

[Snowyowl01 in reply to Lilou1952]

Okay I will ask Gp about that thsnk you so much for your advice x

[Hidden]

Hi,

Have you read the bit of paper in the packets of these drugs. Alot of information is given including info on various categories of side effects.

[Snowyowl01 in reply to Hidden]

Hi, Thanks, yes I have and swelling is not really listed as a side effect.

[HiloHairy]

While I was taking metoprolol and diltiasim (probably misspelled) my right foot and ankle swelled quite a bit. After ablation and off the medications it took greater than a month for the swelling to abate.

[Snowyowl01 in reply to HiloHairy]

Thanks, I didnt realise that it can take sometime before the swelling reduces. I have blood tests tomorrow so see if that indicates any issues. x

[Buffafly]

Diltiazem plus hot weather/standing too much gives me swollen ankles and sometimes fluid retention as well. I fixed the problem by using support socks but not great in hot weather 🥵 Fluid retention does need a diuretic - you can tell if it’s that be checking weight, if it suddenly goes up it may be fluid.

[Snowyowl01 in reply to Buffafly]

Thank you, thats made me feel better, so far not too bad today trying to move around more too which has been difficult following a hip injury few weeks ago.What type of compression socks do you use? x

[Buffafly in reply to Snowyowl01]

Mine were prescribed by my GP surgery - I had them first after an operation but when I developed very bad swollen ankles plus fluid retention one summer I asked a stand-in GP if a short term diuretic would help. She was very dismissive so I was faced with going on holiday without being able to fit any shoes on - not happy! I found a pair of socks I had fortunately kept and they helped so when I returned I cheekily asked for a nurse appointment to get a prescription for more, to my surprise got a Doppler test into the bargain. They are actually thick stockings up to the knee. Worth a try…….

[Snowyowl01 in reply to Buffafly]

Thank you for your advice, I will see if I have any luck getting them prescribed, and yes my concern is that I am going on hols in 2 weeks which involves a flight, so I think I will get the stockings anyway x

[Diddyd]

Also mention at pacing clinic next time you go or give them a ring. You may need a tweak on settings. Also gives you the opportunity to ask about the side effects of those meds from people whose experience may be greater than the GP.

I found a low carb diet and less salt in my diet helped too. It means I can get fluid levels down on my ankles/legs without relying on Furosemide every day

[Snowyowl01 in reply to Diddyd]

Hi, thank you, I did think of ringing the pacing clinic, maybe i will now x

[HiloHairy in reply to Diddyd]

Before my ablation if I had very much salt in a meal It would likely bring on an AFib event. It was rather frustrating as my favorite cuisines are Asian and they tend to use a lot of salt.