Tracy Frech, MD, MSCI: Digital Ischemia for the Rheumatologist

Tracy Frech, MD, MSCI, associate professor of medicine in the Division of Rheumatology and Immunology, Department of Medicine, at Vanderbilt University Medical Center, discusses the key findings from her upcoming American College of Rheumatology State-of-the-Art (ACR-SOTA) presentation, “Digital Ischemia for the Rheumatologist.”

The conversation highlights key points related to digital ischemia assessment and management. Frech emphasizes the importance of starting with a thorough physical examination, including pulse palpation, before considering imaging.

When evaluating a patient with digital ischemia, she says, it's important to first determine if they have a rheumatic diagnosis, as certain autoantibodies are associated with digital lesions. For example, in scleroderma, specific autoantibodies are linked to digital ulcers. Documenting all serologies during the initial visit is crucial to understanding the autoimmune diseases associated with the patient. Oher factors, such as a history of surgical procedures or underlying infections, should also be considered as these comorbidities influence treatment decisions.

Frech underscores the significance of evaluating autoimmune disease markers and understanding comorbidities to tailor treatment effectively. Additionally, the interview touches on the role of specific medications, such as calcium channel blockers and phosphodiesterase inhibitors, in managing digital ischemia and preventing digital ulcers.

One of the key roles of a rheumatologist, Frech explains, is managing Raynaud's phenomenon effectively. This involves asking specific questions about cold-induced finger changes and assessing for demarcation lines or symptoms in other extremities.

Confirming the diagnosis through nailfold capillaroscopy is crucial. Starting vasodilators promptly can improve perfusion and prevent digital ulcers. Early intervention based on meaningful symptoms is essential to prevent critical digital ischemia.

French explains that when differentiating reversible ischemia from critical digital ischemia, consider the blood flow to the finger. Pale fingers with no blood flow indicate critical ischemia, requiring urgent action. Starting with a calcium channel blocker is the first-line treatment, titrated based on blood pressure. Adding a phosphodiesterase inhibitor if necessary can help manage active ulcers. Educating patients about potential side effects like lower extremity edema is also important.

She emphasizes the need for prompt assessment, timely intervention, and collaboration within a multidisciplinary care team to optimize patient outcomes.

Frech has no disclosures to report.