Patients at risk of the progression of chronic venous disease

Abstract

Chronic venous disease is a very common disease in older adults. It expresses various physical signs like varicose veins, oedema, eczema, skin discolouration, and a venous leg ulcer and has a negative impact on the quality of life. Risk factors for the progression of chronic venous disease are not well-known. This thesis to identify risk factors for the progression of chronic venous disease, provide insight into the lifestyle related risk factors, and provides an overview of current chronic venous disease care in the Netherlands. This thesis describes and discusses the results of four studies. The qualitative study among patients with a venous leg ulcer identified four key-themes that patients related to the development of their venous leg ulcer: ‘Comorbidity’, ‘Mobility’, ‘Work & Lifestyle’, and ‘Acknowledgement of chronic venous disease’. Patients also linked the themes to each other (i.e. comorbidity leading to reduced mobility). In addition, known risk factors were identified in a systematic review. Higher age, higher Body Mass Index, low physical activity, arterial hypertension, deep vein reflux, deep venous thrombosis and family history of venous leg ulcers were significantly associated with the development of a first venous leg ulcer. In a scoping review the working mechanisms of obesity and mobility on the development of a venous leg ulcer were investigated. Obesity and reduced mobility can lead to a venous outflow disorder, outflow obstruction and increased adipokine secretion. This can lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction resulting in skin damage. In a cross-sectional study including 74 patients with different stages of chronic venous disease the lifestyle risk factors were further investigated. Logistic regression showed that abdominal obesity (OR 3.9, 95% CI:1.3-12.3) and reduced dorsal flexion (<10˚) of the ankle (OR 5.9, 95% CI:1.8-19.4) were associated with more severe chronic venous disease. Studying physical activity showed that 60% of the study population had multimorbidity that might influence physical activity. Only 34% of the patients met the physical activity recommendations and 39% of the patients reported walking for at least 30 minutes on 5 days per week. Almost 75% of the patients did not engage in 30 minutes of continuous moderate to vigorous physical activity in a week. The median number of steps differed significantly between patients with varicose veins and more severe chronic venous disease (7747 [IQR 5858-9604] vs. 5536 [IQR 4510-8438]). An overview of the current care showed that over 30% of the patients did not receive invasive treatment at the time of the measurements. Non-invasive treatments such as calf muscle exercises, and advice for walking was mentioned by 4%-23% of the patients and non-compliance to wearing compression stockings was 90%. In conclusion, this thesis shows that it is important to assess the patient as a whole person to identify the severity of chronic venous disease and all possible risk factors that are associated with the progression of chronic venous disease. New clinical guidelines should be developed covering adequate screening, diagnostics, treatment, and monitoring of chronic venous disease and its risk factors.