When I am assessing someone with Lymphoedema, heart failure is an important consideration I want to rule out, especially if the clients presents with bilateral leg swelling. Why I want to rule out heart failure, is because heart failure can be a partial or absolute coointroindications to compression garments, bandaging and manual lymphatic drainage (MLD). However, when the heart cannot manage the circulating blood volume effectively, moving additional fluid from the legs back towards the circulation may increase the workload on the heart.
As a Clinical Myotherapist and trained lymphoedema therapist at Melbourne Massage and Treatment Myotherapy and Lymphoedema Clinic in Coburg, I consider a person’s medical history, cardiovascular stability and the likely cause of their swelling before recommending lymphoedema treatment.
In this article, I explain what heart failure is, how compression therapy may help at different levels of heart failure, when compression should be avoided, why MLD is contraindicated in decompensated heart failure, and how eligible Victorian residents may apply for subsidised compression garments through SWEP.
What Is Heart Failure?
Heart failure, as the name suggests, is a medical condition characterised by the difficulties of the heart in pumping blood effectively to meet the body’s needs. This doesn’t mean that the heart has stopped or will stop working, but it means that its pumping function, filling function or both are impaired.
There are different types of heart failure:
- Heart failure with reduced ejection fraction (HFrEF): The heart’s left ventricle has reduced pumping capacity.
- Heart failure with preserved ejection fraction (HFpEF): The heart’s left ventricle has difficulty relaxing or filling properly, despite a relatively preserved ejection fraction.
- Right-sided heart failure: The right side of the heart struggles to pump blood towards the lungs, potentially contributing to fluid accumulation in the legs and abdomen.
- Left-sided heart failure: The left side of the heart struggles to pump blood into the systemic circulation. Pressure may build up in the pulmonary circulation, potentially causing breathlessness and fluid accumulation in the lungs.
More than one of those presentations can coexist at the same time.
Why can heart failure cause swelling in the legs?
While the heart is unable to manage blood circulation, the excess fluid that doesn’t get moved can sit in the system and accumulate. This can also lead to the kidneys retaining sodium and water in response to changes in circulation.
These processes can contribute to fluid moving from the blood vessels into the surrounding tissues, producing peripheral oedema.
Common symptoms and signs of heart failure include:
- Swelling around the ankles, feet and lower legs.
- Shortness of breath during physical activity or at rest.
- Difficulty breathing when lying flat.
- Waking at night feeling short of breath.
- Unusual fatigue and reduced exercise tolerance.
- Rapid weight gain associated with fluid retention.
Leg swelling is not enough to diagnose heart failure, and I am not in any position to be able to diagnose anyone with heart failure.
That said, when someone presents with oedema in their legs, I just want to make sure to rule out heart failure as a cause of the swelling, and if needed, I may refer my client back to the GP for further investigation.
On the other hand, chronic venous insufficiency, kidney disease, medication effects and other conditions can also cause oedema. A medical assessment is important to identify the underlying cause.
While you read this blog, if you are experiencing rapidly worsening breathlessness, chest pain, fainting, or severe breathing difficulty, you require urgent medical assessment. Call 000 for severe or life-threatening symptoms.
Understanding the Severity of Heart Failure
The New York Heart Association (NYHA) functional classification is commonly used to describe how heart failure affects a person’s physical activity and symptoms.
| NYHA class | Functional limitation | Implications for compression |
|---|---|---|
| Class I | No limitation of ordinary physical activity due to heart failure symptoms. | Compression may be appropriate if heart failure is stable and other contraindications have been excluded. |
| Class II | Mild limitation. Ordinary activity may cause fatigue, palpitations or breathlessness. | Compression may be appropriate when clinically stable, usually starting cautiously with lower-leg compression. |
| Class III | Marked limitation. Less-than-ordinary activity causes symptoms. | Avoid routine compression without specialist assessment. Consider only for a clear indication with appropriate clinical monitoring. |
| Class IV | Symptoms may occur at rest, and physical activity causes increased discomfort. | Compression is generally contraindicated, particularly in severe or decompensated heart failure. Specialist management is required. |
Those classes are based on functional symptoms rather than the heart’s ejection fraction and they do not replace a clinical assessment. What you should also be aware of is that heart failure can change over time, passing from one class to another.
When passing from class II to class III, as per the example, compression should be re-evaluated and maybe discontinued. Again, at Melbourne Massage and Treatment, I am not in any position to confirm or recommend compression for heart failure symptom management. This has to be done together with your GP and cardiologist’s assessment and decision-making.
How Can Compression Therapy Help?
What compression therapy has to offer is external pressure to support fluid movement from the tissues towards the lymphatic and venous systems.
Based on the severity of the presentation, treatment may involve graduated compression stockings, adjustable compression wraps or multilayer bandaging. These options are not interchangeable, and the choice should reflect the person’s vascular status, skin condition, limb shape, mobility and ability to apply the garment safely.
In people with stable heart failure, compression may help manage coexisting venous or lymphatic oedema, but is not a treatment for heart failure itself. It is only for oedema management.
1. Stable heart failure: NYHA Class I
When heart failure is stable and there are no significant symptoms during ordinary activity, compression may be considered for a confirmed indication such as venous insufficiency or lymphoedema.
Before recommending compression, I would consider:
- Whether the swelling has been medically investigated.
- Whether the heart failure is stable and adequately managed.
- Whether peripheral arterial circulation is sufficient for compression.
- Whether there are any skin problems, sensory deficits or other contraindications.
- Whether the proposed garment and pressure are appropriate.
If compression is clinically appropriate, we then consider which options work best for your presentation.
2. Stable heart failure: NYHA Class II
Compression may also be appropriate in selected people with stable NYHA II heart failure.
However, applying compression to the legs can displace some fluid towards the central circulation, temporarily increasing venous return and cardiac preload.
For this reason, a cautious approach may be appropriate. International consensus recommendations describe beginning with reduced pressure on one lower leg and gradually progressing, if tolerated, before increasing the treatment area or pressure.
This approach should be guided by the treating medical team and a suitably trained clinician. It is not a protocol to initiate independently in someone whose heart failure stability is uncertain.
3. NYHA Class III: Significant functional limitation
In NYHA III heart failure, ordinary daily activities can cause symptoms, and the heart may have limited capacity to accommodate additional circulatory volume.
Routine compression should therefore be avoided unless there is a clear clinical indication and an appropriate medical management plan.
In selected cases, a specialist may consider carefully controlled, low-pressure compression with clinical and haemodynamic monitoring. This is different from independently prescribing strong compression or treating substantial leg swelling as uncomplicated lymphoedema.
This is where it is really important to establish whether the oedema is predominantly cardiac, venous, lymphatic or multifactorial before deciding on treatment.
4. NYHA Class IV or decompensated heart failure
In severe NYHA IV heart failure or acute decompensated heart failure, compression should generally not be initiated.
Examples of concerning features include:
- Breathlessness at rest or rapidly worsening breathing.
- New or worsening difficulty breathing when lying flat.
- Rapidly increasing leg swelling or body weight due to fluid retention.
- Suspected pulmonary oedema.
- Acute deterioration requiring urgent medical assessment or hospital treatment.
In this situation, the priority is medical stabilisation and management of fluid overload. Compression and MLD should be deferred until the person’s condition has been reassessed and the treating medical team considers them stable enough for treatment.
Important: Do not use compression to manage unexplained or rapidly worsening oedema before assessing for possible cardiac decompensation.
Absolute Contraindications and Major Safety Concerns for Compression
Now that we know that compression therapy can be beneficial, it is important to underline the fact that this form of treatment is not suitable for everyone. That’s why the following conditions require particular attention.
1. Severe or decompensated heart failure
Severe heart failure, particularly NYHA IV, is a contraindication to routine sustained medical compression. Routine compression is also discouraged in NYHA III without a strict indication and appropriate monitoring.
Acute decompensation or pulmonary oedema is a reason to defer compression and prioritise medical care.
2. Severe peripheral arterial disease
Significant arterial insufficiency can make compression dangerous because external pressure may further compromise the blood supply to the tissues.
An international consensus statement identifies the following findings as contraindications to sustained compression in the relevant circumstances:
- An ankle-brachial pressure index (ABPI) below 0.6.
- An ankle systolic pressure below 60 mmHg.
- A toe systolic pressure below 30 mmHg.
- A transcutaneous oxygen pressure below 20 mmHg.
These measurements require appropriate clinical interpretation. If severe arterial disease is suspected, the person should be assessed before compression is considered. And none of those assessments can be completed here at Melbourne Massage and Treatment. Therefore, I will always refer you back to your GP or specialist to get guidance regarding this presentation,
3. Suspected compression of a superficial arterial bypass
Compression over a superficial arterial bypass graft may compromise blood flow. The type and location of the bypass must be considered before treatment.
4. Severe sensory neuropathy or significant skin vulnerability
Severe diabetic neuropathy with sensory loss, or microangiopathy associated with a risk of skin necrosis, requires particular caution. A person who cannot reliably feel excessive pressure may develop tissue damage without recognising it.
5. Confirmed allergy to compression material
A confirmed allergy to the material used in a compression garment is a contraindication to using that material. An alternative should be considered.
Other conditions requiring assessment
There are other conditions that need further investigation from your GP or other practitioners before we commence any form of compression therapy.
For example:
- Acute infection.
- Suspected deep vein thrombosis (DVT).
- Severe or unexplained pain.
- Significant skin damage
- to name few.
These conditions should not all be treated as identical absolute contraindications in every circumstance. For example, appropriately managed DVT is not automatically a contraindication to medical compression; however, a suspected new DVT requires prompt medical assessment.
Is Manual Lymphatic Drainage (MLD) Contraindicated in Heart Failure?
To be immediately clear, MLD is contraindicated in untreated, unstable or decompensated heart failure.
Manual lymphatic drainage is a specialised, gentle manual technique designed to support lymphatic fluid transport. It is commonly incorporated into complete decongestive therapy (CDT) for appropriately assessed patients with lymphoedema.
MLD is contraindicated in untreated or unstable heart failure because it can alter fluid movement towards the central circulation, and in a person whose heart is unable to manage the additional circulatory load, this may aggravate an already unstable condition.
For this reason, I would not provide MLD to a person with suspected or confirmed decompensated heart failure.
So, it is important to distinguish this from stable, medically managed heart failure.
Heart failure is not universally considered an absolute contraindication to every form of MLD in every clinical circumstance. But it is not me who can make the call, thefore I will need a letter of clearance from your cardiologist or specialist to give us the goal for a relevant lymphoedema treatment protocol.
And if you present here for an MLD appointment without the cardiologist’s clearance, I will refer you back to the specialist asking for:
- Whether the heart failure is stable.
- Whether there have been recent hospital admissions or changes in medication.
- Whether there is new or worsening breathlessness, orthopnoea or fluid retention.
- Whether the swelling has been medically investigated.
- Whether the treating medical team considers lymphoedema treatment appropriate.
And again, no treatment would be offered unless I have medical clearance.
Most importantly, MLD should not be used as a substitute for medical management of cardiac oedema. Similarly, reducing swelling does not necessarily mean that the underlying cardiac problem has improved.
Heart Failure and Lymphoedema: Why the Diagnosis Matters
Not all leg swelling is caused by the same mechanism.
A person may have primary or secondary lymphoedema, chronic venous insufficiency, cardiac oedema or a combination of these conditions.
For example, someone with longstanding lymphoedema may subsequently develop heart failure. Their existing lymphatic condition does not disappear, but a new episode of cardiac decompensation can change the safety of their usual compression and MLD treatment.
In these circumstances, treatment may need to be temporarily modified or suspended until the cardiac condition is stable.
I also consider whether the swelling is unilateral or bilateral, how quickly it developed, whether the skin has changed, and whether there are symptoms suggesting venous or cardiovascular disease.
When the cause of swelling is uncertain, I will always seek medical clearance and investigation in priority over starting a lymphoedema treatment programme.
SWEP Application for Compression Garments for Leg Lymphoedema in Victoria
For eligible Victorian residents with diagnosed lymphoedema, the State-wide Equipment Program (SWEP) administers the Lymphoedema Compression Garment Program (LCGP).
The programme provides subsidies for eligible compression garments and wrap systems for primary, secondary or subclinical lymphoedema affecting the limbs.
Who may be eligible?
To be eligible for SWEP you need to:
- Be a permanent resident of Victoria.
- Have a diagnosis of primary, secondary or subclinical lymphoedema affecting a limb.
- Be living independently in the community.
- Meet the programme’s funding requirements, including restrictions on other funding sources and full reimbursement through private health insurance.
The programme determines eligibility through its application process. Having leg swelling alone does not automatically qualify a person for subsidised garments.
How does the application work?
The usual process is:
- Arrange a lymphoedema assessment. Here at Melbourne Massage and Treatment, I am a SWEP-registered lymphoedema practitioner who assesses the condition, medical history, limb measurements and compression requirements.
- Confirm eligibility. At assessment, I can confirm if you are eligible for the Lymphoedema Compression Garment Program criteria.
- Complete the application. I will then submit the relevant online application to SWEP.
- Arrange the appropriate garment or wrap system. Once approved, if there is a payment gap, you will need to cover it, and once it is all paid off, the garments can be ordered via the supplier.
SWEP funding is for eligible compression equipment; it does not mean that every type of swelling is eligible or that every garment will be fully funded. Indeed, WRAP compressions are not.
What if the person has heart failure?
A person with both lymphoedema and heart failure requires assessment of the two conditions. I can offer lymphoedema assessment only.
A SWEP application does not itself establish that compression is medically safe. Before prescribing or fitting compression, we must consider the stability of the heart failure, the likely cause of the oedema, arterial circulation and any other contraindications.
If heart failure is decompensated, routine compression should be deferred while you receive appropriate medical care. Once the condition is stable, than we can determine whether and how compression can be introduced safely.
For further information about SWEP application, use the form below.
Giovanni La Rocca
Giovanni moved to Melbourne, Australia, from Italy in 2008 and became a citizen in 2017. He started studying massage therapy in 2016, then completed a Bachelor of Health Science in Clinical Myotherapy in August 2024. During those years, he also specialised in Thai Massage and Manual Lymphatic Drainage for presentations like Lipoedema and Lymphoedema and recovery from Cosmetic Surgery. Nowadays, he runs his clinic in Coburg, Melbourne, where he integrates movement therapy into his practice to enhance overall well-being. He also values meditation, having completed several Vipassana courses. Committed to continuous learning, he aims to share his expertise in integrated therapies to help others achieve balance and resilience.