Restless Legs Syndrome: Unraveling the Link to Heart Disease

By Kimberly Moskowitz, MD

Most of us roll out of bed each day, hopefully well rested, melee the morning with a cup of coffee or tea then hustle through the day’s cornucopia – driving, standing, working, serving, building, problem-solving, cooking… just fill in the blank.  But, most of us in this busy harried world have at least one thing in common… we all look forward to that moment at the end of the day when we can finally get off of our weary feet, wind down, and relax for a minute or two.  Hopefully most of you are able to enjoy this simple daily indulgence as you breathe in your bouquet of roses.

Unfortunately, lifestyle permitting, this storybook ending to each day is not a luxury granted to all.  At least 80 million Americans, 25% of the U.S. population, come home seeking solace but instead find that their legs are fatigued, swollen, throbbing, aching, painful, cramping, or too restless to find relief.  The leading curable cause of these symptoms is chronic venous insufficiency (CVI), an under-diagnosed and often unrecognized medical condition.  In fact, most people who experience swelling in their legs are evaluated for a cardiac work up and placed on diuretics with no further consideration that treatable vein abnormalities may be an underlying cause.

Restless legs syndrome (RLS) is an appropriately named medical conundrum that affects 10-15% of the U.S. population and is twice as common in women as in men.  At least 39% of patients with RLS also have underlying venous insufficiency and almost 100% of these patients experience relief of symptoms when their veins are treated with EVLT or sclerotherapy.

The hallmark of restless legs syndrome is an overwhelming uncomfortable urge to move the legs during periods of rest, especially just before sleeping at night.  Patients often describe their legs as “creepy crawly”, “antsy” or having the “Heebie-jeebies”.  They also report sensations such as burning, tingling, and cramping that are painful 30% of the time.  Because people with restless legs syndrome often find it difficult to fall asleep at night, the condition is plagued with a high incidence of insomnia, depression, anxiety, daytime fatigue and a feeling of chronic exhaustion.   In addition to nighttime fretfulness, RLS sufferers often find ordinary daytime activities, such as car and plane rides, business meetings, and sitting in movie theaters next to impossible because their legs won’t allow them sit still.

Patients with RLS don’t suffer alone; bed partners also endure their agony as most people with RLS (80%) experience involuntary muscle movements called periodic limb movements of sleep (PLMS) in which the patient has brief “jerks” of the legs or arms during the night.

Numerous studies throughout the U.S. and Europe have shown that frequent awakenings caused by restlessness and periodic leg movements cause nocturnal blood pressure fluctuations that contribute to an increased risk of cardiovascular disease akin to smoking and obesity.

A Harvard-based study published in the online journal Circulation found a connection between RLS and cardiovascular disease by examining health records of more than 70,000 women participating in the Nurse’s Health Study, the world’s largest and longest-running study of women’s health.  The researchers uncovered that women with RLS were about 50% more likely to develop heart disease than women without RLS.  The link was strongest in women who had experienced RLS symptoms for at least three years.

Similarly, an editorial published in the journal Neurology found that men who were diagnosed with RLS had a higher mortality rate from cardiovascular diseases and were approximately 40% more likely to die prematurely compared to men without the condition. It also showed that men with RLS are more likely to be diagnosed with lung disease, endocrine disease, immune system problems, and diseases of nutrition and metabolism.

Although RLS is finally acknowledged as a “real” phenomenon, there are no classical findings on physical exam, no standard radiological or sleep studies to diagnose RLS and no known biomarkers, so diagnosis is made solely by patient reports of having the following RLS criteria:

  • Urge to move legs usually accompanied by unpleasant sensations
  • Worsening of symptoms at rest (lying or sitting down)
  • Improvement of symptoms with movement
  • Worsening of symptoms at night

Primary Restless Legs Syndrome may have genetic causes, and has been associated with low iron storage in the brain and Parkinson’s disease.  Secondary RLS has causes such as diabetes, renal insufficiency, iron deficiency anemia, peripheral neuropathy, thyroid dysfunction, multiple sclerosis, and venous insufficiency.

Venous insufficiency occurs when gravity, hydrostatic pressure, and faulty valves in the leg veins allow blood to flow backwards and pool in the lower half of the body.  This poor blood flow reduces circulation back to the heart and increases pressure in the veins causing venous hypertension, inflammation, and congestion in tissues of the legs.  This stagnant blood flow in the legs equates to a physiological swampy wasteland that accumulates toxic metabolic waste throughout the day causing symptoms of venous insufficiency:  edema, pain, aching, skin discoloration, leg cramping, leg fatigue and restlessness.  65% of people with CVI notice visible varicose veins but the remainder may only have spider veins or their legs can appear normal.

A study published in the journal Phlebology revealed that treatment of varicose veins and underlying venous insufficiency non-surgically with EVLT and/or sclerotherapy relieves symptoms of restless legs syndrome in 98% of patients and 80% of these patients experienced long-term relief.

Restless legs syndrome is one of the newest links in a growing continuum of venous insufficiency and cardiovascular health. To those unknowing, it may seem like a mere nuisance or curiosity, but we have only just begun to unravel the mysteries of both its origins and its cure.  Although restless legs syndrome frustrates most physicians nearly as much as the millions of sufferers, a trained Phlebologist (vein specialist) can improve or cure it almost 50% of the time without surgery or medications.  If your legs twitch and move in the night, don’t let your restless legs lead to a broken heart.

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