Raynaud

Question 1

Epidemiology

Answer 1

5% US pop

most common in young women

seen in families

uncommon in those > 60 yo (prompt eval for secondary)

Question 2

Primary v Secondary

Answer 2

Primary (alone)

• inc vasospastic response OR abnormal reactivity of terminal artery
  
  • Inc cold sensitivity mediated by abnormal alpha2 C receptor (thermo-regulation)

Secondary

• start w/ abnormal underlying vascular anatomy
  
  • Vascular changes –> affect vascular reactivity
  • Endothelial cell dysfunction and initial fibrosis –> vasodilatory imbalance
  • May be inc alpha 2 C adrenergic reactivity just like in primary

Question 3

3 Screening Questions

Answer 3

• 1- are your fingers unusually sensitive to cold?
• 2- do your fingers change color when exposed to cold temp?
• 3- do they turn white, blue or both?

If 2 and 3 negative then not Raynaud’s

Question 4

Hx and PE

Answer 4

• May also ask if stress causes symptoms? are other areas involved? is it very demarcated?
• History - to distinguish b/n primary and secondary
  
  • Age - secondary
  • Occupational
  • Meds
  • Look for systemic signs of underlying diseases - RF, ANA, C3/C4, urinalysis
• PE - rashes, joint findings, muscle weakness, digital pitting scars, skin thickening (all secondary)

Question 5

Nail Fold Capillaroscopy

Answer 5

• Coat skin of nail fold w/ immersion oil then use opthalm
• Primary - normal capillary loops
• Secondary - capillary loop dilation, drop-out, micro-hemorrhages, disorganization

Question 6

Typical Presentation

Answer 6

• Usually starts w/ 1 finger, then spreads to symmetric digits in both hands
• Classic is triphasic - white (ischemic) –> blue (cyanotic) –> reactive hyperemia (rewarming)
• Often numbness and tingling
• Can be provoked by stress
• Fingers&raquo_space; toes

Question 7

Poss Causes of Secondary Form

Answer 7

• Occupational trauma - vibration, frozen food packages
• Drug - anti-migraine, beta blockers, alpha and beta interferons, cocaine, bleomycin
• Obstructive vascular disease - atherosclerosis, micro emboli, thoracic outlet syndrome)
• Blood diseases- polycythemia, malignancy, cryoglobulins, cold agglutinins)
• Autoimmune disease (systemic sclerosis > SLE > myositis > RA)

Question 8

Non-Pharm Tx

Answer 8

• Smoking cessation
• Stay warm (including core)
• Min stress
• Avoid rapid temp changes
• Methods to stop attack - warm water, hands in axilla
• Avoid amphetamines, diet pills, decongestants (all constrict vessels)
• Avoid vibratory tools

Question 9

Pharm Tx

Answer 9

• Ca Channel Blockers - (primary and secondary) nifedipine & amlodipine
  
  • May only need to use in winter months
  • Usually 1st med tried
• Direct vasodilators -
  
  • Topical nitroglycerin (cream or patch); often added if severe w/ ulcers
  • Sildenafil - PDE5 inhibitor (50 mg 2x daily)
• Newer - prostaglandins (dilate) and endothelin-1 receptor antagonists (block constriction)