Chapter 141 - Raynaud phenomenon

Question 1

First description of Raynaud phenomenon

Answer 1

Maurice Raynaud 1862

Question 2

Definine Raynaud’s

Answer 2

1) exaggeration of normal physiologic response
2) episodic pallor/cyanosis caused by vasoconstriction of small digital arteries or arterioles in response to cold or emotional stress

Question 3

Cause of the color change stages in Raynauds

Answer 3

1) pallor = vasospastic attack
2) cyanosis = static blood desaturated
3) rubor = hyperemia from post-ischemic vasodilatation

Question 4

Raynaud’s nomenclature

Answer 4

Raynauds syndrome: all types
Raynauds phenomenon: used to mean secondary now means both

Raynaud’s disease: primary raynauds only

Primary raynaud’s phenomenon = idiopathic and most common
Secondary raynauds phenomenon = underlying disease process

Question 5

Causes of secondary raynauds phenomenon

Answer 5

1) systemic sclerosis
2) rheumatoid arthritis
3) connective tissue disease

has underlying FIXED occlusive disease

Question 6

Epidemiology of raynauds phenomenon

Answer 6

1) prevalence 3.3 - 22%

2) women > men 1.6:1

Question 7

% of people without complete superficial arch

Answer 7

21.5%

Question 8

% of extremities where all 5 digits are supplied by both deep and superficial arches

Answer 8

86%

Question 9

The hunting response in hand

Answer 9

With cold exposure regular rhythmic fluctuation in finger flow with periods of vasoconstriction and vasodilatation very 30sec to 10 min

Question 10

Maximum vasoconstriction in hand occurs at this temperature

Answer 10

10-20 celcius

Question 11

Pathogenesis theories of Raynauds by Raynaud and Lewis

Answer 11

1) hyperactivity of sympathetic NS (Raynaud) - disproven

2) local vascular fault cause increased sensitivity to cold (Lewis)

Question 12

Categories of pathogenesis of Raynauds

Answer 12

1) Vascular
2) Humoral
3) Neural

Question 13

Impaired vasodilatation in raynauds

Answer 13

Decreased NO formation

Question 14

Endothelial-derived relaxing factors

Answer 14

1) NO
2) prostacyclin
3) ATP

Question 15

Diseases with decreased NO formation

Answer 15

1) Raynauds

2) systemic sclerosis

Question 16

Increased vasoconstriction in Raynauds caused by

Answer 16

Increase endothelin 1 concentration and activity

Question 17

Neural pathway at synaptic cleft in response to cold

Answer 17

Cold –> norepinephrine release –> post-synaptic alpha2 receptor –> vascular vasoconstriction

Question 18

Abnormal humoral factors in Raynauds

Answer 18

1) estrogen increase expression of alpha2 adrenoceptors
2) increased serotonin
3) increased thromboxane and B-thromboglobulin
4) increased tpa inhibitor

Question 19

Drugs associated with Raynauds

Answer 19

1) beta-blockers
2) chemotherapeutic agents (vinblastine, bleomycin)
3) bromocriptine
4) amphetamine
5) cocaine
6) ergot

Question 20

Risk factors for Raynauds

Answer 20

1) family history
2) smoking
3) vibration

Question 21

Connective tissue disease associated with Raynauds

Answer 21

1) scleroderma
2) SLE
3) RA
4) Sjogren
5) mixed CTD
6) dermatomyositis, polymyositis
7) vasculitis

Question 22

Occlusive arterial disease associated with Raynauds

Answer 22

1) atherosclerosis
2) Buerger
3) GCA
4) emboli
5) TOS

Question 23

Occupational arterial disease associated with Raynauds

Answer 23

1) Hypothenar hammer

2) vibration

Question 24

Myeloproliferative and hematologic disease associated with Raynauds

Answer 24

1) polycythemia rubra vera
2) thrombocytosis
3) cold agglutinins
4) cryoglobulinemia
5) paraproteinemia

Question 25

Malignancy associated with Raynauds

Answer 25

1) multiple myeloma
2) leukemia
3) adenocarcinoma
4) astrocytoma

Question 26

Infections associated with Raynauds

Answer 26

1) Hepatitis B and C
2) Parvovirus
3) Purpura fulminans

Question 27

Thumb involvement in raynauds

Answer 27

Rare

usually means secondary raynauds

Question 28

Duration of Raynauds attack

Answer 28

10-20 minutes

Question 29

Other associated diseases with primary raynauds

Answer 29

1) Prinzmetal’s angina

2) migraine

Question 30

Diagnostic criteria for primary raynauds

Answer 30

1) vasospastic attack precipitated by cold or stress
2) attack of both hands are asynchronous/asymmetric
3) no tissue necrosis/gangrene
4) no other cause noted
5) normal nail fold capillaries
6) negative serology

Question 31

Most common site of ulnar artery blockade

Answer 31

Hypothenar eminence where it crosses hook of hamate

Question 32

Segmental pressure cutoff for indication of occlusive disease

Answer 32

10 mmHg drop

Question 33

Finger systolic pressure measurement cutoff for disease

Answer 33

15 mmHg between fingers

< 70 mmHg absolute

Question 34

Diagnostic tests for Raynauds

Answer 34

1) vascular lab
2) segmental pressure
3) finger pressure plethysmography
4) cold challenge with temperature measurement
5) nail fold capillary microscopy
6) serology

Question 35

Cold challenge test description for raynauds

Answer 35

1) baseline digital temperature
2) immerse hand in cold 4C for 20 seconds
3) dry hands and warm hand in room temperature
4) length of time to rewarm measured

Rewarming > 10 min suggest raynauds

Question 36

Nail fold capillary in raynauds

Answer 36

enlarged, tortuous and deformed in scleroderma and mixed CTD

Question 37

1st line Treatment for primary raynauds

Answer 37

Prevention and avoid stressors

Question 38

dihydropyridine Calcium channel blockers in treating raynauds types

Answer 38

1) Nifedepine 10-30 mg po qd-tid (most extensively studied)
2) Nicardipine 20-50 po bid
3) amlodipine 10 mg po daily
4) felodipine 5-20 mg po daily
nisoldipine 5-10 po daily

Question 39

Non-dihydropyridine calcium channel blockers in raynauds

Answer 39

1) Diltiazem 30-120 mg po tid
2) Verapamil no benefit

less side effect than dihydropyridine but not as effective

Question 40

Side effect of dihydropyridines

Answer 40

1) hypotension
2) flushing
3) edema
4) palpitations
5) dizziness

Question 41

Alpha 1 recepto antagonist in raynauds

Answer 41

1) Prazosin 1 mg po tid (useful in secondary raynauds)

2) Terazosin 1 mg po daily

Question 42

Other classess of drugs in Raynauds

Answer 42

1) ACEi (captopril, enalopril, quinapril)
2) ARB (losartan)
3) SSRI (fluoxetine)
4) PDVi (sildenafil, tadalafil, vardenafil)
5) Nitrate (topical nitroglycerin)
6) prostaglandins (epoprostenol, iloprost)
7) endothelin receptor antagonist (bosentan)

Question 43

Surgical therapy in raynauds

Answer 43

1) Botulinum toxin
2) Sympathetic block
3) thoracoscopic sympathectomy (high recurrence in primary raynauds but helps in secondary)
4) digital sympathectomy
5) spinal cord stimulators
6) acupuncture
7) laser therapy