Swollen ankles combined with breathlessness — especially on exertion or when lying flat — is heart failure until proven otherwise. This guide explains the causes, the tests, and why early assessment changes outcomes dramatically.
Ankle swelling and breathlessness together suggest fluid accumulation — either from heart failure (commonest), kidney disease, liver disease, or venous insufficiency. The combination warrants assessment, not just compression stockings.
The most important cause — fluid accumulates in the lungs (breathlessness) and ankles (oedema) when the heart cannot pump efficiently. BNP blood test and echocardiogram confirm. Highly treatable.
Protein loss through damaged kidneys reduces blood oncotic pressure, causing generalised oedema including ankles. Urine ACR and kidney function tests identify it.
Low albumin production by a failing liver causes fluid to leak — ankle swelling and abdominal ascites. Liver function tests and abdominal scan identify it.
Incompetent leg veins causing fluid accumulation in the ankles — worsens through the day, improves overnight. No breathlessness unless combined with another cause.
One-sided swollen, tender, warm calf or ankle — especially after a long flight or inactivity. Not breathlessness unless PE has occurred.
Puffy oedema (myxoedema) — non-pitting ankle and face swelling with fatigue, cold intolerance, and weight gain. TSH test diagnoses it.
BNP (B-type Natriuretic Peptide) — A blood test — elevated BNP confirms cardiac strain and is the primary test for heart failure. Available at Mascot Healthcare.
ECG (Electrocardiogram) — Assesses heart rhythm and identifies previous heart attack or thickening — done in clinic in 10 seconds.
Echocardiogram (Heart Scan) — Measures ejection fraction — how well the heart is pumping. Definitive test for heart failure type and severity.
Kidney Function + Urine ACR — Creatinine, eGFR, and urine albumin — excludes kidney disease as the cause.
Liver Function Tests + Albumin — Identifies liver cirrhosis as a cause of low oncotic pressure and fluid accumulation.
Thyroid Function (TSH) — Excludes hypothyroidism as a contributing cause of non-pitting ankle oedema.
Ankle swelling + breathlessness together always warrants assessment the same day — not "after the weekend."
Does it worsen through the day? (suggests venous/cardiac). Is it present all day? (suggests systemic cause). Is it one leg only? (suggests DVT).
Rapid weight gain (> 2 kg in 2 days) with ankle swelling and breathlessness suggests worsening fluid retention — come in immediately.
While awaiting assessment, reduce salt drastically — high salt intake worsens fluid retention from any cause.
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