22 - 145 - RAYNAUD PHENOMENON Flashcards
Which is not true with Raynaud phenomenon?
a. Thumbs are most commonly affected
b. 90% of patients have systemic sclerosis
c. Often in 2 nd decade of life
d. F>M
A
In Raynaud Phenomenon, if pain is present during this phase/s, a secondary cause is more likely.
a. Cyanotic
b. Pallor/Pale
c. Hyperemia/bright red
d. A and B
B
What is the critical part of evaluation in Raynaud phenomenon?
a. Inspect the capillaries in the proximal nailfold
b. Inspect for hand edema
c. Inspect for telangiectasias
d. Inspect for sclerodactyly
A
Potential diagnosis of systemic sclerosis, except?
a. Inspect the capillaries in the proximal nailfold
b. Inspect for hand edema
c. Inspect for telangiectasias
d. Inspect for sclerodactyly
A
All are true descriptions of Allen test in Raynaud phenomenon, except:
a. assess arterial and venous function of the hands
b. simultaneously compresses the radial and ulnar arteries
c. Patient open and closes the fist to induce blanching of the palm
d. Positive test should be confirmed with a more definitive diagnostic evaluation such as doppler or angiogram
A
p. 2614 (arterial and capillary function)
Variety of medications can cause or exacerbate RP, examples are as follows, except:
a. Vinblastine
b. Clonidine
c. Oral contraceptives
d. Amphotericin B
e. None
E
Helpful adjunctive tool to predict progression of RP to SSc.
a. Thermal imaging
b. Nailfold capillaroscopy
c. Doppler imaging
d. Finger systolic pressure measurement
B
Not a feature of Raynaud crisis:
a. Rapidly progressive nailfold
b. Chronic
c. Catastrophic tissue ischemia
d. Medical emergency
B
- represents an exaggerated physiologic response to cold or emotional stimuli caused by functional changes in blood vessels and their innervation
- it does not result in tissue injury
Primary (idiopathic) RP
form of RP which occurs as a result of a systemic disorder or drug exposure, is distinguished by a more aggressive course that can lead to profound tissue ischemia and eventuate in cutaneous ulceration, scarring, or digital gangrene
Secondary RP
features suggestive of secondary RP
- pain prominent during ischemic (pallor) phase
- cutaneous ulceration
- thumb involvement
- Persistent ischemic discoloration in spite of rewarming
- Trophic changes of the digits - signs of prolonged attacks of RP
abnormal nailfold capillary pattern
capillary enlargement and/or capillary loss
microvascular damage, which can be assessed by evaluating the proximal nailfold capillaries, is an independent predictor for progression to SSc, highlighting the importance of this examination finding
This test should be performed to assess arterial and capillary function of the hands. How do you perform this test?
Allen test
- In this test, the examiner simultaneously
compresses the radial and ulnar arteries, while the patient opens and closes the fist to induce blanching of the palm. - Selective arterial filling is judged by the
rate of color return as pressure is sequentially released from the radial and ulnar arteries. - Abnormal filling implies structural disease of the microcirculation, raising the suspicion for a secondary form of RP or the presence of a thrombus.
tests for diminution of the radial pulse with exaggerated movement of the neck and shoulder
Adson maneuver
Features predictive of
progression of primary to secondary RP
- nailfold capillary abnormalities,
- hand edema (puffy hands),
- positive Allen’s test,
- antinuclear antibodies
most common cause of secondary RP
connective tissue diseases
most common cause of iatrogenic RP
β-Adrenergic blockers
- Unopposed peripheral vasoconstriction likely accounts for the development of RP, and specific drugs within the class, for example, propranolol, exhibit a higher propensity to cause disease than do other drugs
nailfold capillaroscopy findings highly specific for and can predict transition to SSc
- capillary dilation (giant capillaries) with focal hemorrhage and areas of avascularity (capillary dropout)
Criteria for Primary Raynaud Phenomenon
To satisfy a diagnosis of primary RP, patients must have evidence of their fingers having unusual cold sensitivity, experience **at least biphasic color changes **during vasospastic episodes (white and blue), and have a minimum of 3 of the following features present:
- attacks triggered by stimuli other than cold (eg, emotional stress);
- involvement of both hands, even if asymmetric;
- attacks accompanied by numbness or paresthesias;
- color changes characterized by a well-demarcated border between affected and unaffected skin;
- photographs that strongly support a diagnosis of RP;
- episodes occurring at other body sites (eg, nose, ears, feet, and nipples); and
- triphasic color changes (white, blue, red).
rapidly progressive form of RP that is characterized by acute, potentially catastrophic tissue ischemia and is considered a medical emergency
Raynaud crisis
Patients with secondary RP should be alerted to the possibility of developing this rare complication, which is heralded by extreme pain and persistent white-blue color changes in a digit that will not rewarm.
preferred first-line therapy for both primary and SSc-associated RP in patients who do not respond to behavioral modification alone
Calcium channel blockers (CCBs)
The dihydropyridine class of CCBs (nifedipine, amlodipine, nicardipine, and felodipine) are the least cardioselective and appear to be the most efficacious in terms of reducing the frequency and severity of attacks of RP
Medications typically reserved for Raynaud crisis.
an oral endothelin receptor antagonist
Bosentan
