2. Screening for Cardiovascular Risk in SCI

Screen for cardiovascular risk factors at least annually.

The Problem

Cardiovascular disease (CVD) is a leading cause of death among people with SCI. Risk for CVD is higher than for the general population, and key risk factors for CVD are exacerbated by SCI; specifically, dyslipidemia, blood pressure irregularities, abnormal glycemic control, chronic inflammation, autonomic nervous system dysfunction, obesity, and physical inactivity. Early onset CVD is part of a pattern of premature aging among people with SCI. In many instances, CVD is asymptomatic because of impaired sensation and lack of strenuous activity. Lifetime prevalence is estimated at 30-50%, but may actually be as high as 60-70%, given asymptomatic cases.

Evidence-based Best Practice

Aggressive screening is required in order that under-diagnosis and conservative treatment do not add to the burden of disability.

  • Waist circumference > 37” (94 cm) in supine lying is a better indication of obesity than BMI, although at risk BMI has been calibrated at 22/21 for males/females with quadriplegia, and 26/28 with paraplegia.
  • Blood pressure should be measured at every encounter. Resting BP should be <140/90 mmHg. Also be aware of fluctuations and potential for autonomic dysreflexia (See Nugget #4).
  • The Framingham Risk Score may underestimate CVD risk in the SCI population. The National Cholesterol Education Program’s Adult Treatment Protocol III is recommended as a more accurate classification of lipid levels for the SCI population (see below).
  • HDL levels should be <40 mg/dL for men or <50 for women; LDL should be <159.
  • Hemoglobin A1C profiles should be assessed annually > 40 years of age for men, or >50 for women.
  • Plasma glucose should be >100 mg/dL; 2-hour glucose tolerance should be >200.
DesirableBorderline high riskHigh riskVery high risk
Total cholesterol< 5.25.2 – 6.2> 6.2
Low-density lipoprotein (LDL)< 3.33.4 – 4.14.1 – 4.9> 4.9
High-density lipoprotein (HDL)> 1.51.0 – 1.3 (men)
1.3 – 1.5 (women)
<1.0 (men)
<1.3 (women)
Triglycerides < 1.71.7 – 2.22.3 – 5.6> 5.6

Key Reference

Yarar-Fisher, C.,, Heyn, P., Zanca, J. M., Charlifue, S., Hsieh, J. & Brienza, D. M. (2016). Early identification of cardiovascular diseases in people with spinal cord injury: Key information for primary care providers. Archives of Physical Medicine and Rehabilitation, 98(6), 1277-1279. doi:10.1016/j.apmr.2016.10.001

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Adriaansen, J. J. E., Douma-Haan, Y., van Asbeck, Floris W. A, van Koppenhagen, C. F., de Groot, S., Smit, C. A., . . . ALLRISC. (2017). Prevalence of hypertension and associated risk factors in people with long-term spinal cord injury living in the netherlands.Disability and Rehabilitation, 39(9), 919-927. doi:10.3109/09638288.2016.1172349

Aidinoff, E., Bluvshtein, V., Bierman, U., Gelernter, I., Front, L., & Catz, A. (2017). Coronary artery disease and hypertension in a non-selected spinal cord injury patient population.Spinal Cord, 55(3), 321-326. doi:10.1038/sc.2016.109

Köseoğlu, B. F., Safer, V. B., Öken, Ö., & Akselim, S. (2017). Cardiovascular disease risk in people with spinal cord injury: Is there a possible association between reduced lung function and increased risk of diabetes and hypertension?Spinal Cord, 55(1), 87-93. doi:10.1038/sc.2016.101