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Episode 19 : Raynaud's Disease: A Condition of Vasospasm of Arteries That Happens with Cold or Stress

Release Date: July 10, 2007

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. We're very excited to be able to bring excellent, easy to understand science to you on all topics relating to heart and blood vessel diseases as a public service. As a public education forum, the Vascular Disease Foundation is made up of representatives of the premiere medical and science advisory groups in the country that relate to vascular diseases. These are groups that use peer-reviewed science to verify that the information you are getting is nationally recognized as the very best and most reliable data available.

Today's topic is by special request. Most of our previous topics have dealt with vascular diseases which are occlusive, meaning that due to wear and tear on the vessels, calcium build-up, plaque build-up, damage to vessels and formation of blood clots, the blood flow to that area has been limited. The limitation in blood flow causes harm to the different areas of the body, such as stroke, heart attack, dysfunction of the legs, pain, ulcerations, and even at times, amputations. We have a different phenomena we'd like to discuss today. What happens when there is no discreet blockage or damage to the arteries, yet somebody has pain and dysfunction? We'll be talking about a dynamic process whereby a fundamental difference between artery and veins can in part explain how certain symptoms can occur and certain of these problems occur often, but not always, in younger people too. This information comes from a very special guest. Dr. Heather Gornik is a cardiologist and vascular disease specialist at the Cleveland Clinic. She's the Medical Director of the noninvasive vascular laboratory and a colleague of mine. Dr. Gornik, I'll call you Heather, we've spoken before, you've done this program before; we're so grateful that you are joining us on the HealthCast microphones.

Dr. Heather Gornik: Thank you David, I'm delighted to be here again.

Dr. David Meyerson: So let me start, this is an interesting one because this is, again as I pointed out in our introduction, most of what we've talked about before have been diseases where the blood vessel slowly becomes occluded, the walls of the arteries are damaged, there is calcium build-up and plaque build-up and cholesterol build-up and then the area, the endothelium, the inner lining of the blood vessel wall becomes disrupted and blood clots begin to form and all kinds of nastiness happen. That's our sixty-year-old house analogy where the plumbing begins to be bad in one area, it's bad in others and it's no surprise that when you find disease in one place in that sixty-year- old house, that you could find disease in another. But you and I are going to discuss something a little different and before I tell the listeners exactly what we call this phenomenon, why don't I ask you just for a moment, what is the fundamental difference between arteries and veins?

Dr. Heather Gornik: Oh sure. Well, --

Dr. David Meyerson: That's an interesting place to start, right because you know where I'm going and I know where I'm going, but the audience doesn't, so I think this is a good building block.

Dr. Heather Gornik: Yes. Absolutely. So they're actually David, three types of blood vessels in the body, the arteries, the veins and the lymphatic vessels. And the arteries are the blood vessels that carry oxygen rich blood from the heart to the muscles, organs and tissues of the body. The veins are the blood vessels that tend to have thinner walls than the arteries that carry the blood back from the tissues and the muscles and organs after the oxygen has been used by these structures, carries it back to the heart and the lungs to get repleted with oxygen. The third type of blood vessel is called the lymphatic vessels and these are vessels mainly in the skin that help deliver some fluid from the tissues back to the veins and back to the heart to be oxygenated again and to start this process over and over again.

Dr. David Meyerson: So if we're talking about a plumbing system for starters, the arteries are the pipes that bring the fresh water to wherever we're going to use it, whether it be a kitchen or a bathroom and the veins are really the drains, if you will that take that used blood and bring it back for reprocessing.

Dr. Heather Gornik: Exactly.

Dr. David Meyerson: Okay and I want to get to one more piece of that because you alluded to it before, but one of those vessels has a thick arterial wall that actually has tone to it, or muscles have tone in our body you know, when we work out our musculature is more toned, our biceps and triceps and all kinds of muscularity like that, but which of the vessels has this thicker walled tone blood vessel that can react and change its caliber?

Dr. Heather Gornik: The arteries of the body and actually the smaller arteries have a lot of muscle tone that's able to adapt very quickly to a situation where the muscles need more oxygen for example, if you're exercising, then this muscle layer on these small arteries actually adapts to increase blood flow.

Dr. David Meyerson: So the -- normally the arteries of the arms and legs can actually dilate or widen --

Dr. Heather Gornik: That's right.

Dr. David Meyerson: -- and narrow or constrict in response to changes in the environment such as temperature, like you just said.

Dr. Heather Gornik: Exactly.

Dr. David Meyerson: And there are mechanisms that govern what the tone in those arteries should be. Now, let me take us a little bit further then, so that if we are very hot. If our body temperature is too high, then the blood vessels can actually dilate and allow the skin to radiate more heat. Is that right?

Dr. Heather Gornik: That's correct.

Dr. David Meyerson: So it's a -- NASA would love this system because it's complex thermoregulation. That's one of their biggest problems, right?

Dr. Heather Gornik: Absolutely.

Dr. David Meyerson: All right, let me take you a step further now so that the audience is going to bring us into this area. So you have a teenager, okay. A wonderful, it could be a sixteen-year-old guy or a girl, but a kind of interested student, a good athlete, etcetera, etcetera. They get themselves into a nervous situation and all of a sudden, their hands are ice cold. Now these sixteen-year-old teenagers, could be a boy or a girl, probably have nearly the best circulation on the planet, but their hands are ice cold. This is not a -- they don't have blockages in their arteries leading to the hands, do they?

Dr. Heather Gornik: Correct. I think what they have is what is the topic of today's discussion which is a temporary spasm or temporary closure of the small vessels of the hands and feet.

Dr. David Meyerson: And so they have – and this is a normal thing for when people get nervous, their hands can become cold and maybe a little clammy sometimes, but generally they're not having any pain and they get over their nervousness and everything turns to normal.

Dr. Heather Gornik: That's right.

Dr. David Meyerson: What happens? There's a phenomenon whereby people's blood vessels are much more reactive than they're supposed to be and there's a situation where some people -- we've heard that some people can pick up -- let's say it's the winter time and you're playing with your kids, let's say a forty-year-old mom decides that she's going to pick up snow and make a snowball and get into a little snowball fight and finds that she tries to make the snowball and all of a sudden, her hands start turning colors and they become painful. What's going on? And here's where we can really introduce our topic today.

Dr. Heather Gornik: Sure. Well, this is something called Raynaud's Phenomena.

Dr. David Meyerson: Could you spell that for us?

Dr. Heather Gornik: Raynaud's is R-A-Y-N-A-U-D-S --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: -- and that's named after a physician, I believe, whose name was Maurice Raynaud and basically Raynaud's Phenomenon is spasm or temporary constriction of the blood vessels, the arteries, of the hands and feet usually in response to something like cold, but can also happen in response to stress. And this is actually a very, very common phenomenon. I don't really want to call it a disorder or disease because in many cases, it's very, very benign.

Dr. David Meyerson: Uh-huh [affirmative]. It only becomes a disease when it really begins to interrupt somebody's lifestyle or ability to function, right?

Dr. Heather Gornik: That's right or in some cases where Raynaud's Phenomenon can be a symptom of another underlying disorder, such as an arthritis type disorder, but in over half of the cases, Raynaud's Phenomenon is very, very benign and something I very commonly see in my practice. And as you mentioned, the classic case of Raynaud's Phenomenon is a young patient usually while in his or her twenties or thirties, typically female although men can also have Raynaud's Phenomenon, but usually four women for every man will have the Raynaud's Phenomenon and these people have episodes of discomfort and discoloration of their fingers or toes in response to cold or stress and usually patients often report that their hands and feet change a rainbow of colors. First they'll notice, when they first feel the discomfort that their fingers look a little white or pale. A minute or two later, things may look a little blue or purple and then as the pain seems to lessen and the spasm of the blood vessel resolves, there's actually a rush of blood into the fingers and the fingers actually get red, pink or warm. So patients often report these three phases of color changes and some discomfort in the hands and again, this usually happens in response to either cold or stress.

Dr. David Meyerson: It seems to be the only patriotic disease process that I'm aware of --

Dr. Heather Gornik: Yes.

Dr. David Meyerson: The red, white and blue.

Dr. Heather Gornik: White, exactly.

Dr. David Meyerson: And I understand from my reading that -- and my practice that they don't have to come exactly in that order, the white, blue and red. Sometimes they can vary a little bit.

Dr. Heather Gornik: That's true and some patients will only notice the blue and the red or some patients may only notice white and red or some patients may just notice the blue. So there is a spectrum of presentation, but I think the common denominator is that these episodes, there's usually some discomfort associated with the color changes and all --

Dr. David Meyerson: I understand the skin can look a little bit swollen at times when this phenomena's going on as well.

Dr. Heather Gornik: Yeah, sometimes. Absolutely.

Dr. David Meyerson: And throbbing and tingling and real discomfort at times.

Dr. Heather Gornik: Yes.

Dr. David Meyerson: And so what do you tell them? Don't make the snowball, right?

Dr. Heather Gornik: Well, I think the most important thing is in most cases, this is entirely benign --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: -- and you can imagine that someone would be very concerned if all of a sudden their fingers are changing white and purple and red and oftentimes patients are very concerned they could have a serious vascular disorder, so --

Dr. David Meyerson: So do you want to lump, I'm sorry -- separate those two in what you might call primary Raynaud's? Do you actually pronounce the D? Some people, I think is a French pronunciation, they may say Raynaud and I think here, we just say Raynaud's, right?

Dr. Heather Gornik: Correct. Yes.

Dr. David Meyerson: So there are a spectrum people that you just mentioned that are otherwise perfectly normal and these people just have this hyper reactivity. Is that right?

Dr. Heather Gornik: That's correct and these are patients who generally we can manage very, very -- with very simple measures such as telling patients to stay warm, wear gloves when you're doing your grocery shopping and going in the frozen food aisle, even if it's summertime, wear gloves. Keep your body, core body temperature warm so wear a hat and a sweater and oftentimes, these simple measures can totally treat the problem. You alluded to the primary versus secondary Raynaud's and just to catch the audience up to speed, primary Raynaud's Phenomenon is these episodes of the color changes and spasm of the blood vessels of the hands and feet when there's really no other associated problem and generally these are very mild episodes. The color changes resolve completely after the exposure to cold and usually this can be managed conservatively.

Dr. David Meyerson: Is this the quintessential cold hands, warm heart?

Dr. Heather Gornik: Yes. I think that may very well be true. I never thought of it that way. The secondary Raynaud's is a little bit more worrisome and when a patient may want to consult with a vascular specialist and that's when there are episodes of the spasm or color changes that last for long periods of time, for hours or days. When there's a sore that develops on one of the fingers or one of the toes, this is very worrisome. When Raynaud's happens at unexpected times, for example, a man in his eighties, that would be a very unusual time to develop the Raynaud's Phenomenon for the first time.

Dr. David Meyerson: So what you're saying is that there are clues for the patient and the physician that there is an underlying process that should be looked for.

Dr. Heather Gornik: Exactly.

Dr. David Meyerson: Before we get to what those underlying processes would be, let's talk just for a second about the diagnosis, the differential diagnosis of cold and painful hands as opposed to cold and painful feet because as a vascular disease specialist, you would be more concerned perhaps about one more than the other.

Dr. Heather Gornik: I think both are concerning. I think what you're alluding to is for patients who have cold and painful feet, first and foremost, we need to make sure there is not very severe peripheral arterial disease or severe, severe blockages in the arteries of the legs leading to a critical loss of blood flow to the feet and that would really be a vascular problem that requires urgent treatment.

Dr. David Meyerson: To the audience, this is outstanding because it's clear that Heather knows precisely what I'm thinking. You're clairvoyant and that's exactly the area I wanted you to address.

Dr. Heather Gornik: Yeah.

Dr. David Meyerson: We really must make certain that all of the occlusive diseases that we mentioned at the very beginning, the ones caused by cholesterol and calcium and wear and tear on blood vessels and blood clots, etcetera, we need to make certain that that's not present because those could cause very, very serious problems and they're all treatable and largely preventable as we've mentioned so many times on this program and so Heather, once you've made certain that we're not dealing with a harmed, bad plumbing if you will with all of the things that we have just mentioned, then where do you go?

Dr. Heather Gornik: Well, then I think a lot of this can be done on the basis of a physician's physical exam. You know, I examine the patient and make sure that this is not a large artery plumbing problem, as you mentioned and then after that and perhaps some additional tests in our vascular lab, if I'm confident that this is a spasm of the blood vessels in the hands and feet, I would investigate why this is happening. Are we dealing with one of these very benign primary Raynaud's cases for which we don't really have an underlying cause and this is a very benign problem, not really a disease, or are we dealing with a very severe case of vasospasm perhaps related to an underlying disorder that we need to intensively investigate and treat.

Dr. David Meyerson: And then there are other causes that are come short of diseases that probably triggering those at times. Would a smoker be more likely to get Raynaud's than the next person?

Dr. Heather Gornik: I think that's an honestly -- is a little bit controversial. I would say smoking certainly, if you have Raynaud's, makes it worse, so absolutely you should not smoke and I recommend that all patients who have Raynaud's quit smoking, absolutely.

Dr. David Meyerson: Let's go a step further, as long as we're on the smoking, let's recommend that nobody smokes.

Dr. Heather Gornik: Of course.

Dr. David Meyerson: There is no other product that is currently marketed to American society that when used as directed is harmful and will kill and cigarettes when even used as intended are harmful and will kill. They cause this blood vessel disease that we've talked about, heart attacks and strokes and

Heather, I think if we can just spend about thirty seconds more on this commercial, there is nothing that a young person can do that will invest more in their future, functional and long-term health and well-being than smoking cessation, if they're a smoker. Wouldn't you say?

Dr. Heather Gornik: I agree entirely.

Dr. David Meyerson: And to those of you who are thinking about cutting down, I think Heather and I would say well cutting down is good, but that only means that you're driving -- is the equivalent of saying I'm only driving a hundred and thirty-five miles a week two days a week, so you're going to get killed on a Tuesday or a Saturday. Please, it's not worth it. There is no other product that we use that when used as designed, it will over time, kill you. It is just that simple. I would encourage our smokers to look in the mirror, look at themselves and say, "My goodness, who am I kidding?" You must stop smoking. If you are putting away money for retirement and smoking, you're just doing two things that are totally opposite. So Heather, thank you for the forbearance on that.

Dr. Heather Gornik: Yeah, absolutely. Yeah. Very important.

Dr. David Meyerson: And in terms -- as a vascular disease specialist, you have seen in your practice and I see in cardiology here at Hopkins, enormous numbers of lives that have been ruined by cigarette smoking, both from cancers and blood vessel diseases.

Dr. Heather Gornik: Absolutely. Lives and limbs lost also.

Dr. David Meyerson: Absolutely. What are the other -- there are some other diseases that we should probably mention briefly as causes of the secondary Raynaud's Phenomena? By the way, when the patient's in the examining room, do you actually put their hands in ice water to see if you can trigger the response?

Dr. Heather Gornik: Believe it or not, sometimes we do.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: If a patient comes in describing these symptoms and we don't see any evidence of the spasm on our examination and it's important to really see if this is what's happening, we often do submerge the hands in a bath of ice water and actually measure the blood flow after the ice water challenge. So we do do that. We also sometimes, if people have spasm when they're in our office, put the hands in warm water to see how much we can improve the blood flow.

Dr. David Meyerson: Are certain medications likely to trigger or worsen Raynaud's?

Dr. Heather Gornik: Some medications can. There's a number of medications that we really don't use very commonly anymore for various disorders, but some medications can worsen Raynaud's Phenomenon and those include things like the ergotomines that are used to treat migraines --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: -- some of the cancer chemotherapy drugs, some antidepressants can actually worsen Raynaud's Phenomenon, oral contraceptives in some patients can make Raynaud's worse and one area that's a little bit controversial with regard to Raynaud's are the beta blockers, which are actually very important drugs for treating heart disease and high blood pressure, but in some patients can cause Raynaud's Phenomenon.

Dr. David Meyerson: And then there's a whole spectrum of what we might call connective tissue or rheumatologic diseases that may be the underlying process whereby Raynaud's is caused or worsened. Is that right?

Dr. Heather Gornik: Yes. And in my practice when I see an elderly patient who has not had Raynaud's until again, if I described their seventies or eighties, or when Raynaud's causes ulcers of the fingers, this is usually the underlying cause and this includes things like scleroderma or lupus or other rheumatologic disorders.

Dr. David Meyerson: And there for people who are really bothered by this, you said that there are simple ways, you said that you avoid cold exposure, but there are some medications that are also valuable if patients are really that uncomfortable?

Dr. Heather Gornik: Absolutely. I should preface this by saying David that there are no medications specifically on the United States drug market that have been approved for Raynaud's Phenomenon, so basically we are using medications that are used for other things and in general we use medications that are used to treat high blood pressure. I think the most effective medication for relief of severe vasospasm from Raynaud's are things like calcium channel blockers --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Heather Gornik: -- or alpha blockers, or even nitroglycerin. And these are all drugs that are used for other things that --

Dr. David Meyerson: Well you and I both use these drugs commonly for people --

Dr. Heather Gornik: Yes.

Dr. David Meyerson: -- that we believe might have some component of spasm of the arteries that nourish the heart muscle, the coronary arteries.

Dr. Heather Gornik: That's right.

Dr. David Meyerson: And so the nitrates that you mentioned and the calcium channel blockers do have some value. There is some research in an unusual type of medicine, there is -- people hear so often, the term -- the erectile dysfunction medication such as Viagra and the other medicines in that group --

Dr. Heather Gornik: Yeah.

Dr. David Meyerson: -- and it's interesting that in people with very high blood pressure going to the lungs, pulmonary hypertension, those medications are being looked at with great favor now and might the same process be useful with somebody who has Raynaud's because they do improve blood supply?

Dr. Heather Gornik: I'm glad you mentioned this. For patients with very severe Raynaud's and this is usually the secondary Raynaud's that's associated with something like arthritis disorder, or scleroderma, the basics of keeping, maintaining warm body temperature and limb temperature and the alpha blockers and calcium blockers and nitrates are just not effective enough and we need to use very potent medications to treat the Raynaud's and a couple of medications have actually been tried and have shown some great effectiveness for severe Raynaud's in the past few years, one of which is the class of drugs used to treat erectile dysfunctions, so Sildenophil or often known as Viagra, is sometimes used in cases of very severe Raynaud's and has been very effective in helping people with severe hand symptoms and healing sores on the fingers, so we often do use those same drugs that we use sometimes for pulmonary hypertension to treat severe Raynaud's. But again, I want to emphasize that this is one out of every twenty patients. I would say fifteen out of twenty respond to just staying warm --

Dr. David Meyerson: Right. Almost no therapy.

Dr. Heather Gornik: -- and an additional four need a calcium blocker and then maybe one out of twenty is using these other medications.

Dr. David Meyerson: Heather, this has been very, very informative. It's a whole different area because we haven't spoken that much about the vasospasm type of disease processes and you certainly brought us a lot further along and I'm very grateful. You've been listening to Dr. Heather Gornik. She is the Medical Director of the Noninvasive Vascular Laboratory at the Cleveland Clinic. She is a -- like me, she is a cardiologist and vascular disease specialist there and we are so grateful for your participation today. For the Vascular Disease Foundation, and for Dr. Kerry Stewart our engineer and producer, and from me, I'm Dr. David Meyerson and thank you so much for listening. Have a good day.

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