Raynaud Phenomenon Outcomes: Transition to Secondary Diseases
ABSTRACT & COMMENTARY
Synopsis: Only 13% of Raynaud phenomenon patients developed a secondary disorder, most of which were connective tissue diseases. The best predictor of whether anyone proceeded was an abnormal nailfold capillary pattern.
Source: Spencer-Green G. Arch Intern Med 1998;158: 595-600.
Primary raynaud phenomenon or reversible vasospasm of the extremities has always been taught in the rheumatology section of medical school lectures. We know it can be caused by repetitive vibration, certain vasospasm-inducing drugs (e.g., ergotamine), smoking, frostbite, or vinyl chloride exposure; it could also be vascular or autoimmune in origin.
Spencer-Green answered the important question of how many of these primary Raynaud phenomena proceeded to develop a secondary disease by looking at population-based surveys. He turned his attention to published reports of Raynaud phenomenon, looking at the frequency rates and types of diseases that evolved in these patients. He found 10 studies with a total of 639 patients; the average age at entry was 42 years. Raynaud phenomenon has been around for about eight years, with follow-up about four years. During the follow-up, about 13% of the patients (81/639) developed another disease, most of which (80) were connective tissue diseases. By using statistical analysis, the author looked at abnormal nailfold capillary pattern, cutaneous lesions, positive antinuclear antibody test (ANA), abnormal pulmonary function, esophageal dysmotility, and digital ulcers or pits. Spencer-Green was able to delineate an odds ratio of whether any of these had a positive predictive value or not. He found that the most significantly predictive was abnormal nailfold capillary pattern.
Only 13% of the patients with Raynaud phenomenon developed a secondary disease, and most of the time it was connective tissue disease. Nailfold capillary pattern was the most predictive of a transition. This is the largest meta-analysis of Raynaud phenomenon to date.
COMMENT BY LEN SCARPINATO, DO
All primary care physicians know about Raynaud phenomenon and, specifically, the pain on exposure to cold. The fingers turn white, then blue, then red in alternative order, but the pain is the hallmark condition. Many of us have suspected a correlation with connective tissue diseases which goes back to when we were taught this material in medical school, along with the other connective tissue diseases. I, for one, didn't know the correlation with development of those secondary diseases, but I had always wondered.
Spencer-Green has helped me immensely by doing this meta analysis. I now know that only about 13% of these patients move on to a secondary disorder, which is reassuring. During my history, I have ruled out etiologies such as vibration, ergotamine, frostbite, and vinyl chloride. With all that ruled out, I can be reassured that the majority of patients (87%) will not develop anything more than the Raynaud that they have. Now I can reassure my patients.
Another way of helping them would be to look at nailfold capillary patterns. This isn't something that I have spent a tremendous amount of time on, but I have done it in the past and am going to have to relearn it. Other findings that were positive were telangiectasias, puffy fingers, or sclerodactyly. Not surprisingly, the ANA once again has not helped me.
In clinical practice, I will be able to reassure my patients. If I do a little more sophisticated physical exam, I'll be able to tell even more to a patient about whether they will develop a secondary tissue disorder.
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