3. Management of Cardiovascular Risk in Patients with SCI

Manage cardiovascular risk among patients with SCI as you would a high-risk ambulatory patient.

The Problem

Management of CVD risk is challenging with SCI, due to altered sympathetic and parasympathetic nervous system functioning. SCI affects CVD risk not only directly through hypertension, dyslipidemia and increased insulin resistance, but also indirectly through obesity and decreased muscle mass due to paralysis. Recent studies suggest that hypotension (lesions above T1) and arterial stiffness (lesions below T7) may also result in cognitive deficits over the long term.

Evidence-based Best Practice

Aggressive treatment of cardiovascular risk factors is essential to minimize risk for cardiovascular disease.

  • Pharmacological management: Guidelines for high risk patients apply for pharmacological management of hypertension, dyslipidemia and diabetes. Pharmacological management of obesity is contraindicated.
  • Nutritional management: Obesity has been estimated at 50-75% in the SCI population, and significant nutritional inadequacies have been found. Recommend heart-healthy diet with <5% saturated fat and <2400 mg sodium. Refer for indirect calorimetry to assess energy needs and expenditures.
  • Lifestyle management: Evidence-based guidelines recommend 150 minutes per week of moderate to vigorous aerobic activity, as well as resisted strength training for major muscle groups. Popular modes of exercise include arm ergometry, wheelchair propulsion, wheelchair sports, swimming, circuit training and electrically stimulated cycling. Prior to participation in physical activity, patients should be made aware of the potential for overuse injuries (see Nugget #7: Management of Musculoskeletal Pain), autonomic dysreflexia, thermal dysregulation (see Nugget #4: Autonomic Dysreflexia).
  • Smoking cessation: is also a key part of effective lifestyle management. Evidence has shown that lifestyle changes are significantly more likely to be sustained if monitored by a physician.

Key Reference

Nash, M. S., Groah, S. L., Gater Jr, D. R., Dyson-Hudson, T. A., Lieberman, J. A., Myers, J., … & Consortium for Spinal Cord Medicine. (2018). Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Topics in Spinal Cord Injury Rehabilitation, 24(4), 379-423.

Actionable Nuggets (4th ed., 2019)

Additional References (see 2016)

Nightingale, T. E., PhD, Metcalfe, R. S., PhD, Vollaard, N. B., PhD, & Bilzon, J. L., PhD. (2017). Exercise guidelines to promote cardiometabolic health in spinal cord injured humans: Time to raise the intensity?Archives of Physical Medicine and Rehabilitation, 98(8), 1693-1704. doi:10.1016/j.apmr.2016.12.008

Nash, M. S., Tractenberg, R. E., Mendez, A. J., David, M., Ljungberg, I. H., Tinsley, E. A., . . . Groah, S. L. (2016). Cardiometabolic syndrome in people with spinal cord Injury/Disease: Guideline-derived and nonguideline risk components in a pooled sample.Archives of Physical Medicine and Rehabilitation, 97(10), 1696-1705. doi:10.1016/j.apmr.2016.07.002

Bigford, G., & Nash, M. S. (2017). Nutritional health considerations for persons with spinal cord injury.Topics in Spinal Cord Injury Rehabilitation, 23(3), 188-206. doi:10.1310/sci2303-188

La Fountaine, M. F., Cirnigliaro, C. M., Hobson, J. C., Dyson-Hudson, T. A., Mc Kenna, C., Kirshblum, S. C., . . . Bauman, W. A. (2018). Establishing a threshold to predict risk of cardiovascular disease from the serum triglyceride and high-density lipoprotein concentrations in persons with spinal cord injury.Spinal Cord, 56(11), 1051-1058. doi:10.1038/s41393-018-0187-7