#3 - Compression therapy and CHF
Safety of compression therapy for venous ulcer disease in the setting of congestive heart failure
Robert R Attaran, Amanda Cavanaugh, Cynthia Tsai, Tariq Ahmad, Cassius O’ Chaar, Scott Persing and Henry Hsia
Phlebology. 2020 Feb 6:268355520905178
Compression therapy in patients with venous ulceration and congestive heart failure (CHF) represents an area of concern for many practitioners, especially those new to practice. I selected this article because it specifically addresses this issue.
This is a retrospective review of patients with CHF who underwent compression therapy at the wound care center at Yale New Haven Hospital between January 2013 and June 2019. They only included patients with stable CHF, defined as heart failure not requiring hospitalization, supplemental oxygen therapy, IV diuretics or inotropic drugs. Patients with critical limb ischemia were excluded from the study. Types of compression were determined by the treating physicians and were unna boot (7.4%), multilayer (73.7%), stockings (15.8%), lymphedema pump (2.1%), and ace bandage (1%). Data collected included dosage of diuretic therapy, body weight and renal function. Pre-intervention values were obtained 30 days prior to compression and post-intervention values were obtained 7-30 days after initiation of therapy. Admissions for decompensated CHF were recorded. The data obtained was compared against the general CHF population for the medical center as wells as a large national registry.
A total of 95 patients were identified and commenced compression therapy. A diuretic dosage increase was made in 6 (6.3%) patients in the first 30 days post-initiation of compression. A total of 7 (7.3%) of patients were admitted for CHF exacerbation during the compression therapy, but the mean duration of compression was 310 days and the earliest any of the 7 patients decompensated was 49 days after initiation of compression therapy. There was no significant rise in mean body weight 7-30 days post initiation of compression and only 3 (3.2%) patients had a greater than 5 kg or more gain in weight.
The admission rate of 7.3% for the 310 day mean compression period compared favorably to the general CHF population annual decompensation admission rate for the facility of 17% for systolic CHF and 20.7% for diastolic CHF. It also compared favorably to the CHF registry with a readmission rate of 33.3% within the year.
Among the 95 patients included in this study, 17 (17.9%) healed completely, 41 (34.1%) did not heal and 37 (39%) did not have follow-up information of ulcer healing. The authors did not report how long the follow-up period was for determining healing.
The authors concluded that for this study, there was no evidence that the initiation of compression therapy triggered a decompensation of CHF in patients with stable CHF.
My interpretation: While this may be a retrospective study from a single institution, these results confirm the experience I have in my own clinical practice that compression therapy is safe in patients with stable CHF. However, there are limitations to the study that need to be kept in mind. It appears the authors are relying on determining the admission rate for the study patient if they presented to their own facility. If a patient was admitted to a different facility, that would not have been captured. Given that the authors do not have data on ulcer healing for 39% of the study population, this could be significant. Also, the authors did not define the follow-up time period they used to determine ulcer healing. A healing rate of 17.9% is well below the rates seen in other studies cited in the article as well as below my own personal experience. If indeed this is the true healing rate for these patients, this would lead to a question of if adequate compression was applied. To definitively answer the question of the safety of compression therapy in patients with CHF, a larger study with better follow-up is needed, however, patients with stable CHF and venous ulceration are unlikely to heal without compression therapy, and if properly selected these patients should be able to safely undergo compression therapy.