ONTHEOCCURRENCEOFDYSPNEA,DIZZINESS ANDPRECORDIALDISTRESS OCCASIONEDBY THE POOLINGOF BLOOD

IN VARICOSEVEINS

By EARLE M. CHAPMANAND ERLING ASMUSSEN(From the Massachusetts General Hospital and The Fatigue Laboratory,

Harvard University, Boston)

(Received for publication January 13, 1942)

Varicose veins of the legs are known to havelocal secondary effects such as edema of the leg,eczema of the skin, ulceration and even hemor-rhage. Sequelae such as thrombosis and phlebitisof the enlarged veins may in turn cause pulmonaryemboli with their distressing pulmonocardiac symp-toms. However, we can find no clear evidencein the medical literature that the pooling of bloodin varicose veins leads to a decrease in the effi-ciency of cardiac and circulatory function.' It isour intention to present here evidence, both clini-cal and physiological, indicating that such a formof circulatory embarrassment occurs in varyingdegrees in persons who have varicose veins.

The failure in the past to recognize this typeof decrease in circulatory function may be due inpart to the fact that the symptoms are usuallymoderate in nature and seldom lead to actual car-diac failure. However, fatigue, dyspnea, dizzi-ness, fainting and precordial distress are symp-toms that may trouble the patient in whom theheart is burdened to maintain its compensation.These symptoms should be recognized as possiblybeing the effect of pooling of blood in varicoseveins. Surgical treatment of such patients shouldrestore their hemodynamics toward normal andthus bring relief from their symptoms, providedthat the heart has not been permanently damaged.In the aged and in those with known heart disease,

1 Near the completion of this work we discovered inthe lectures of John Gay in 1867 (1) a description of avaricose old lady who described a correspondence be-tween the venous distention and her dyspnea. After sur-gical treatment her dyspnea was much relieved. Like-wise, in November 1940, Lee and Freeman (2) describedcirculatory disturbances produced by extensive angiomataof the lower extremities associated with varicose veins.In one of their three cases, attacks of 'fainting on standingwere prevented by the wearing of an elastic stocking andfinally saphenous ligation brought permanent relief ofsymptoms.

the added burden from varicose veins may beenough to provoke severe symptoms.

The erect posture imposes a certain strain onthe circulatory system even in normal individuals.The increased hydrostatic pressure in the legs andin the lower parts of the body causes a dilatationof blood vessels and a local accumulation of blood.Asmussen, Christensen and Nielsen (3) have es-timated that in normal persons standing still, 500cc. of blood or even more accumulate in the legs.Consequent to such stagnation a smaller amountof blood is available in the central veins emptyingback into the heart; this decrease in venous returnlessens the filling of the heart and results in adecrease in the cardiac output when standing; afall in blood pressure under these conditions maybe followed by a sudden increase in pulse ratewhich is probably accomplished via the pressure-sensitive zones in the aortic arch and the carotidsinus and also by a compensatory contraction ofthe blood vessels in the abdominal viscera. Thedecrease in the cardiac output of normal, standingindividuals has been observed by Asmussen (3),Grollman (4), and Sweeney and Mayerson (5).In fact, two normal subjects of Schneider andCrampton (6) became dizzy on quiet standingfor fifteen minutes and one fainted.

The idea that varicose veins could cause unduedyspnea, dizziness and precordial distress origi-nated in the practice of medicine when one of uswas consulted by a middle-aged woman in soundhealth who complained of attacks of severe pre-cordial pain on walking and sometimes on suddenstanding. The clinical story suggested angina orcoronary heart disease but careful examinationof the heart disclosed no evidence of disease andthe roentgenogram and the electrocardiogram ofher heart were normal. The observation of herlarge varicose veins suddenly led to the idea thatpooling in these veins might have caused such a

393

EARLE M. CHAPMANAND ERLING ASMUSSEN

decrease in venous return to the heart that inade-quate filling of the heart resulted in a deficientcoronary blood flow and so caused pain. Relieffrom this patient's symptoms was obtained byhaving her wear elastic stockings on both legs.

With this experience in mind, we next inter-viewed a large number of persons with varicoseveins of sufficient size to allow considerable venouspooling. Two hundred and fifty patients inthe Out-Patient Department of the MassachusettsGeneral Hospital, so afflicted, were questioned.The surprising result of this was to find that 47(18 per cent) of the 250 complained of undueshortness of breath that was relieved in the re-cumbent position; 19 of these 47 also sufferedmild precordial pain, palpitation, or were uncom-fortably aware of their heart action, and 3 werewomen who experienced attacks of sudden dysp-nea, dizziness and precordial pain, simply onstanding. These 47 patients were without grosssigns of the known types of heart disease, althoughin some the blood pressure was slightly elevated.

With this background in clinical evidence, wenext turned to the laboratory for data that mightexplain these symptoms and also the changes thatoccur in the circulation of persons with largevaricose veins.

METHODS

In this investigation we had planned to observe 12normal persons and 24 patients with varicose veins, 12of whom had symptoms such as described here and thenrepeat our studies after operative procedures to obliteratethe venous reservoirs. However, certain practical con-siderations, including the sudden return of one of us(E. A.) to Denmark, have allowed us to complete ourobservations on only 7 normal and 12 varicose subjects.Of these 12, 5 had the symptoms mentioned; 7 returnedfor study after operation and 4 of these were withsymptoms.

Wefirst obtained normal, untrained subjects and con-firmed the previous observations of Grollman, Asmussen,and Mayerson that the change from the recumbent tothe upright position causes a decrease in the cardiacoutput in the tilted position. Conversely, Schneider andCrampton observed an increase in the cardiac output inchanging from quiet standing to the recumbent position.Seven normal subjects were taken to the laboratory inthe morning in a fasting state and placed in a recumbentposition on a tilt table. After a rest period, the basalmetabolic rate, vital capacity, pulse rate and blood pres-sure were measured. An estimation of the arteriovenousoxygen difference was made by the Grollman acetylene

method (taking the samples at intervals of 18 and 23seconds), and the cardiac output was computed from thebasal oxygen consumption and the A-V oxygen difference.The subject then was tilted passively to a 45° angle andthe observations were repeated. In most subjects anelectrocardiogram was taken in both positions.

Twelve patients with rather large, untreated varicoseveins were then studied; 5 of these 12 had the symptomsmentioned before, chiefly dyspnea and dizziness, and 1woman described particularly severe attacks of shortnessof breath, dizziness and fainting on getting suddenly outof bed.

Finally, 3 to 17 months after these patients had hadhigh saphenous ligations and injections of sclerosingsolutions for their varicose veins, we succeeded in getting7 of them back to the laboratory and repeated our ob-servations. The upper photographs of Figure 1 showthe subject P. D. with large varicose veins; the lowerphotographs show his legs 6 months after this treatment.

RESULTS AND DISCUSSION

In our patients with varicose veins it is evidentthat an amount larger than 500 cc. of blood ac-cumulates in their veins during standing and walk-ing. Consequently, the same physiologic responsescould be expected but in a greater order of magni-tude. We likewise observed this decrease in thecardiac output in the tilted position of our normalbut untrained subjects. The accompanying databest illustrate these responses. We did not un-dertake to estimate the amount of blood in theveins of the legs for several reasons. First,plethysmographic methods necessitating pressureabout the thigh would necessarily introduce anerror, and second, the approximate knowledge ofthe amount pooled in no way explains the physio-logic response; it only indicates the degree of theresponse.

Figure 2 shows that the 7 normal subjects werepractically the same age as the patients and thatour results agree satisfactorily with the normalvalues established by Grollman and by Asmussen,Christensen and Nielsen. The cardiac index (car-diac output per square meter of body surface) isnot only constant under fixed conditions but likethe basal metabolism is predictable, according toGrollman, for normal individuals. It will be notedthat the cardiac index and the stroke volume 2 arehigher than normal when subjects with varicose

2The stroke volume is the amount of blood ejectedwith each systole and its value multiplied by the pulserate gives the cardiac output in liters per minute.

394

SYMPTOMSFROM BLOOD POOLING IN VARICOSE VEINS 395

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FIG. 1. SUBJECT P. D. WITH LARGE VARICOSE VEINS; THE LOWERPHOTOGRAPHSSHOWHIS LEGS 6MONTHSAFTER SAPHENOUSLIGATION AND INJECTION

EARLE M. CHAPMANAND ERLING ASMUSSEN

RECUMBENT

7 Normal Subjects

12- PatientsVaricose

NormalGrol Imon'sA4mussen

CardiocIndex

ASystolicBlood

Pressuremm.

StrokeVol.cc.

1Blood

Vol.per sq.

m.

45 degrees

PASSIVE

Decline in {ecine[ Decrease mncrCardiac

out-put

StrokeVol.

in Syst.B. P.

Pulse

Rate

45 2.10- 125 65 5. % 14. N%o 0.3% 15. .%48 2.91 140 80 3.30 21.% 39.% 8. . 25.I

2.2, l 62 2.53 112.36 1 2'.93 1

FIG. 2. CIRCULATORY FUNCTIONS OF NORMALSUBJECTS COMPAREDWITH PATIENTS WITH VARICOSE VEINS

veins are recumbent. The reason for this may

be that with varices there is a greater blood vol-ume and so in the recumbent position a greateramount of blood returns to the heart. This issuggested by the high average blood volume of3.30 liters per square meter' of body surface, com-

pared with the normals established by Gibson andEvans (7) using the same technique. Their val-ues for normal males were 2.93 and for females2.53. Our high value indicates an added loadin the circulation.

From Figure 2 it is also evident that on tilt-ing these subjects and filling their varicose veinsthe cardiac output fell about four times as muchas it did in the normal subjects and the systolicblood pressure was somewhat lowered but never

enough to suggest a postural hypotension. Pos-sibly it is this comparatively great fall from a

higher than normal level of cardiac output whichcauses the symptoms described here. Kerr (8)described relief of dyspnea and anginal pain byhaving his patients with a pendulous abdomenwear an abdominal belt. The situation may beanalogous with the pooling of blood in the legsin one case, and in the abdominal cavity in theother. When tilted, the average cardiac indicesin the normal persons and in those with varicoseveins, both before and after operation, were stillwithin the normal range (Table I). However,analysis of individual responses shows that in4 of 6 patients the cardiac output in the tilted

position is definitely lowered after the treatmentfor the varicose veins. This further supports theexplanation that an actual reduction of the loadin the circulation was accomplished by removalof the venous reservoir, and could explain theclinical fact that many patients note fewer symp-

toms of fatigue after the obliteration of theirengorged veins.

Figure 3 shows the measurements of circulatoryfunctions that were made several months aftercorrective operations for the varicosities of 7subjects. In all but 1 subject (F. B.) highcardiac indices had been -present and after re-

moval of their venous reservoir this value becamenormal in 2 and lower in 2; also in 6 of the 7, theblood pressure when recumbent was lowered.Likewise the decreases in stroke volume and bloodpressure on tilting became much less in all except 2subjects. From the last column it can be notedthat the increase in pulse rate on tilting became nor-

mal in all but these same 2 after operation. These2 subjects deserve particular comment. M.MacD.had symptoms of dyspnea and dizziness and oftenfainted if she got out of bed and stood up sud-denly. Following saphenous ligations she had no

further such attacks and the decline in strokevolume on tilting was less. However, moderatevarices in her right leg persist. The other sub-ject, F. B., was an obese fireman who continuedto be obviously short of breath on effort althoughhe denied symptoms; tilting him occasioned a

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Averages 3.03 2.64 140 129 239.7 227 14.2 6.7 27.3 14.2

FIG. 3. CIRCULATORYFUNCTIONS BEFOREAND AFTER SAPHENOUSLIGATION FOR VARICOSE VEINS

great fall in stroke volume but this was compen-sated by a considerable increase in the pulse rate.The explanation for both these subjects may bethat the obliteration of the varices is incomplete.

Table I contains all the data in our investiga-tion and from this we have prepared Figures 2and 3. Referring to Table I one notes that thechanges in blood volume per square meter of bodysurface suggest that less blood is actually presentin circulation after the venous reservoirs are re-moved, however, this comparative data is toolimited for interpretation. The vital capacity ofthese subjects showed no consistent changes.Electrocardiograms were done in the recumbentand tilted positions on the 7 subjects indicated.There was a slight lowering of the T-wave inLead II in the tilted positions of T. S. andF. K., a known physiologic change (9). How-ever, in S. D. there was marked lowering ofT1 and T2 and slurring of QRS3 and fifteenminutes after the graph was taken she faintedand the blood pressure became unobtainable. Thismay have been a reaction to postural hypotensionas an exaggerated response to her peripheral pool-ing. In a recent careful study of 3 patients withpostural hypotension, Stead and Ebert (10) didnot state that their subjects were without varicoseveins.

Probably the most significant observation wemade was the increase in pulse rate on tilting.Comparison of the two last columns in Figure 3indicates this response. The definite rise in pulserate on tilting is of course a compensatory mecha-nism to offset the fall in stroke volume and tomaintain the cardiac output. The average in-crease in pulse rate of all 7 before ligating theveins is twice that after ligation. By applicationof the previous formula,3 this indicates to us thatcirculatory efficiency has been definitely increasedby removal of the blood pool in the varicose veins.

CONCLUSIONS

We believe that undue fatigue, shortness ofbreath, dizziness, fainting, and precordial dis-tress may be occasioned by the pooling of bloodin varicose veins. These clinical investigationsoffer evidence that the circulatory efficiency isdecreased by such extensive pooling and that re-moval of this peripheral blood reservoir restoresthe hemodynamics of the subjects toward normaland relieves their symptoms.

We are indebted to Dr. W. H. Forbes for doing theblood volume determinations and his advice.

3See footnote 2.

398

SYMPTOMSFROMBLOODPOOLING IN VARICOSE VEINS

PROrOCOLS

Case 1.4 E. C.: A 44-year old woman managing afarm. She had bilateral varicose veins for at least 12years and complained of some undue shortness of breath,fatigue, and occasional dizzy spells while at work. Fol-lowing ligation and injection she was greatly improvedand noted less fatigue and shortness of breath.

Case 2. T. S.: A 65-year old gardener who said hisvaricose veins had been present for 35 years. They were

particularly large on the left side and extended to thegroin. He denied discomfort in any way.

Case 3. S. D.: A 40-year old Polish housewife whohad bilateral varicose veins for 7 years. She spoke littleEnglish, but no history of dyspnea, dizziness, or faintingwas obtained. However, on tilting her she had a fall inblood pressure and fainted, making further study im-possible.

Case 4. B. A.: A 53-year old Hebrew storekeeperwith large bilateral varices of 7 years duration. Heworked standing each day and denied symptoms exceptsome aching in the legs. However, he wore supportivebandages most of the time.

Case 5. F. K.: A 36-year old meat smoker (the man

in the glass house at the World's Fair) who for 3 years

had huge varicose veins reaching both knees. He deniedsymptoms but after operation he observed that he couldthen walk 5 to 10 miles without fatigue or shortness ofbreath.

Case 6. G. B.: A 43-year old housewife who for 19years had large varicosities of both legs, more extensiveon the right where they reached the groin. She com-

plained of undue shortness of breath and often sighedheavily and was frequently dizzy. Following ligation andinjection she was greatly improved and had a greatertolerance for work.

Case 7. M. MacD.: A 50-year old housewife who hadlarge varicose veins coursing up both legs to the groin.For 20 years these had troubled her. She complained ofshortness of breath and also of sudden attacks of pre-

cordial pain and dizziness when she got out of bed andstood up. On several occasions she had fallen in a faint.After ligation of her veins she was greatly improvedand no longer had such attacks. However, moderatevarices in the right leg persisted.

Case 8. R. B.: A 48-year old Polish housewife whohad bilateral varicose veins of 10 years duration. Shedid not complain.

Case 9. A. M.: A 47-year old Russian emigre woman

with large varicosities extending above both knees.

4We consider cases 1, 3, 6, 7, and 12 to have thesymptoms described.

These had been present many years and she had nocardio-respiratory symptoms.

Case 10. M. N.: A 55-year old Irish workman whohad had a large pattern of varicose veins extendingabove his knees for the previous 20 years. He was atense, restless fellow smoking 40 cigarettes daily anddenying symptoms referable to his circulatory system.

Case 11. P. D.: A 64-year old retired fireman withthe varicosities shown in Figure 1. He was withoutparticular complaint, but said he felt better and fatiguedless after their obliteration.

Case 12. F. B.: A 39-year old obese railroad firemanwho had bilateral varicosities for 20 years. They werelarger on the right and reached above the knee. Hedenied symptoms but was obviously short of breath onslight effort.

BIBLIOGRAPHY

1. Gay, J., On Varicose Disease of the Lower Extremi-ties and Its Allied Disorders: Skin Discoloration,Induration and Ulcer; being the Lettsomian Lec-tures 1867. John Churchill and Sons, London,1868.

2. Lee, W. E., and Freeman, N. E., Circulatory dis-turbances produced by extensive angiomata of thelower extremities associated with varicose veins.Ann. Surg., 1940, 112, 960.

3. Asmussen, E., Christensen, E. H., and Nielsen, M.,The regulation of circulation in different postures.Surgery, 1940, 8, 604.

4. Grollman, A., The Cardiac Output of Man in Healthand Disease. C. C. Thomas, Baltimore, 1932.

5. Sweeney, H. M., and Mayerson, H. S., Effect ofposture on cardiac output. Am. J. Physiol., 1937,120, 329; Mayerson, H. S., Sweeney, H. M., andToth, L. A., Influence of posture on circulationtime. Am. J. Physiol., 1939, 125, 481.

6. Schneider, E. C., and Crampton, C. B., The effect ofposture on the minute volume of the heart. Am.J. Physiol., 1934, 110, 14.

7. Gibson, J. G., 2nd, and Evans, W. A. Jr., Clinicalstudies of the blood volume. II. The relation ofplasma and total blood volume to venous pressure,blood velocity rate, physical measurements, age,and sex in ninety normal humans. J. Chin. Invest.,1937, 16, 317.

8. Kerr, W. J., The treatment of angina pectoris bymethods which appear to promote more adequatefilling of the heart. Am. Heart J., 1938, 16, 544.

9. Scherf, D., and Weissberg, J., The alterations of theT-waves caused by a change of posture. Am. J.M. Sc., 1941, 201, 693.

10. Stead, E. A., Jr., and Ebert, R. V., Postural hypo-tension. Arch. Int. Med., 1941, 67, 546.

399