2. Screening for Cardiovascular Risk in SCI

Actionable Nuggets for SCI (2nd ed., 2013)

Screen for cardiovascular risk factors at least annually.

 The Problem:

Cardiovascular disease (CVD) is the leading cause of death among people with SCI. As part of a pattern of premature aging, cardiovascular disease has an earlier onset with SCI. Symptoms of CVD are prevalent in 30-50% of the SCI population. Asymptomatic CVD (due to impaired sensation) may be prevalent in 60-70% of people with chronic SCI.

Evidence-based Best Practice:

A number of key risk factors for CVD are exacerbated by SCI, such as dyslipidemia, blood pressure irregularities, abnormal glycemic control, chronic inflammation, autonomic nervous system dysfunction, obesity, and physical inactivity. Aggressive screening and preventive management are required in order that under-diagnosis and conservative treatment do not add to the burden of disability.

Blood pressure should be measured at every encounter, and at least annually. Plasma lipid and hemoglobin A1C profiles should be assessed annually in men after 40 years of age, and in women who are at least 50 years of age or postmenopausal. Results may be used to calculate the Framingham Risk Score, an estimate of the 10-year risk for developing CVD, although this 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.

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:

    Dyson-Hudson, T.A., & Nash, M.S. (2009). Guideline-driven assessment of cardiovascular disease and related risks after spinal cord injury. Topics in Spinal Cord Injury Rehabilitation14(3): 32-45.

Additional references:

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    Bauman, W.A., et al. (1993). Tomographic thallium-201 myocardial perfusion imaging after intravenous dipyridamole in asymptomatic subjects with quadriplegia. Archives of Physical Medicine & Rehabilitation74(7): 740-4. http://dx.doi.org/10.1016/0003-9993(93)90036-A
    Bauman, W.A., et al. (1994). Cardiac stress testing with thallium-201 imaging reveals silent ischemia in individuals with paraplegia. Archives of Physical Medicine & Rehabilitation75(9): 946-50. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8085927
    Bauman, W.A., et al. (1998). The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury. Spinal Cord36(1): 13-7.http://dx.doi.org/10.1038/sj.sc.3100513
    Bauman, W.A., & Spungen, A.M. (1994). Disorders of carbohydrate and lipid metabolism in veterans with paraplegia or quadriplegia: a model of premature aging. Metabolism43(6): 749-56. http://dx.doi.org/10.1016/0026-0495(94)90126-0
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    Canadian Diabetes Association (2008). Clinical practice guidelines for the prevention and management of diabetes in Canada. Canadian Journal of Diabetes32(Suppl 1): S1-S201.http://www.diabetes.ca/for-professionals/resources/2008-cpg/
    Canadian Task Force on Preventative Health Care (2012). Recommendations on screening for type 2 diabetes in adults. Canadian Medical Association Journal184(15):1687-96.
    The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension. 2010 [cited 2010 April 28, 2010]. http://hypertension.ca/chep.
    Chen, Y., et al. (2006). Obesity intervention in persons with spinal cord injury. Spinal Cord44(2): 82-91. http://dx.doi.org/10.1038/sj.sc.3101818
    Chilibeck, P.D., et al. (1999). Functional electrical stimulation exercise increases GLUT-1 and GLUT-4 in paralyzed skeletal muscle. Metabolism48(11): 1409-13.http://dx.doi.org/10.1016/S0026-0495(99)90151-8
    D’Agostino, R.B., Sr., et al. (2008). General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation117(6): 743-53.http://dx.doi.org/10.1161/CIRCULATIONAHA.107.699579
    de Groot, P.C., et al. (2003). Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord41(12): 673-9. http://dx.doi.org/10.1038/sj.sc.3101534
    DeVivo, M.J., Black, K.J., & Stover, S.L. (1993). Causes of death during the first 12 years after spinal cord injury. Archives of Physical Medicine & Rehabilitation74(3): 248-54. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8439250
    Eichler, K., et al. (2007). Prediction of first coronary events with the Framingham score: a systematic review. American Heart Journal153(5): 722-31, 731 e1-8.http://dx.doi.org/10.1016/j.ahj.2007.02.027
    El-Sayed, M.S., & Younesian, A. (2005). Lipid profiles are influenced by arm cranking exercise and training in individuals with spinal cord injury. Spinal Cord43(5): 299-305.http://dx.doi.org/10.1038/sj.sc.3101698
   Elder, C.P., Apple, D.F., Bickel, C.S., Meyer, R.A., & Dudley, G.A. (2004). Intramuscular fat and glucose tolerance after spinal cord injury-a cross-sectional study. Spinal Cord42(12):711-6.
    Finnie, A.K., Buchholz, A., & Martin Ginis, K.A.; SHAPE-SCI Research Group (2008). Current coronary heart disease risk assessment tools may underestimate risk in community-dwelling persons with chronic spinal cord injury. Spinal Cord46(9): 608-15.
    Garshick, E., et al. (2005). A prospective assessment of mortality in chronic spinal cord injury. Spinal Cord43(7): 408-16. http://dx.doi.org/10.1038/sj.sc.3101729
    Genest, J., et al. (2009). Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult – 2009 recommendations. Canadian Journal of Cardiology25(10): 567-79.http://www.pulsus.com/journals/abstract.jsp?sCurrPg=abstract&jnlKy=1&atlKy=9081&isuKy=877&isArt=t&fromfold=
    Gibson, A.E., Bushholz, A.C., & Martin Ginis, K.A.; SHAPE-SCI Research Group (2008). C-Reactive protein in adults with chronic spinal cord injury: Increased chronic inflammation in tetraplegia vs paraplegia. Spinal Cord46(9): 616-21.
    Groah, S.L., Nash, M.S., Ward, E.A., Libin, A., Mendez, A.J., Burns, P., Elrod, M., et al. (2011). Cardiometabolic risk in community-dwelling persons with chronic spinal cord injury. Journal of Cardiopulmonary Rehabilitation and Prevention31(2): 73-80.
    Hetz, S.P., Latimer, A.E., Buchholz, A.C., & Martin Ginis, K.A.; SHAPE-SCI Research Group (2009). Increased participation in activities of daily living is associated with lower cholesterol levels in people with spinal cord injury. Archives of Physical Medicine and Rehabilitation90(10): 1755-9.
    Jeon, J.Y., et al. (2002). Improved glucose tolerance and insulin sensitivity after electrical stimulation-assisted cycling in people with spinal cord injury. Spinal Cord40(3): 110-7.http://dx.doi.org/10.1038/sj.sc.3101260
    LaVela, S.L., et al. (2006). Diabetes mellitus in individuals with spinal cord injury or disorder. Journal of Spinal Cord Medicine29(4): 387-395. http://www.ncbi.nlm.nih.gov/pubmed/17044389
    LaVela, S.L., Evans, C.T., Prohashka, T.R., Miskevics, S., Ganesh, S.P., & Weaver, F.M. (2012). Males aging with a spinal cord injury: Prevalence of cardiovascular and metabolic conditions. Archives of Physical Medicine and Rehabilitation93(1): 90-5.
   Lee, C.S., et al. (2006). Evaluating the prevalence of silent coronary artery disease in asymptomatic patients with spinal cord injury. International Heart Journal47(3): 325-330.http://dx.doi.org/10.1536/ihj.47.325
   Mohr, T., et al. (2001). Insulin action and long-term electrically induced training in individuals with spinal cord injuries. Medicine and Science in Sports and Exercise, 33(8): 1247-52. http://dx.doi.org/10.1097/00005768-200108000-00001
    Myers, J. (2009). Cardiovascular disease after SCI: Prevalence, instigators, and risk clusters. Topics in Spinal Cord Injury Rehabilitation14(3): 1-14.
    Nash, M.S., et al. (2001). Circuit resistance training improves the atherogenic lipid profiles of persons with chronic paraplegia. Journal of Spinal Cord Medicine24(1): 2-9.http://www.ncbi.nlm.nih.gov/pubmed/11587430
    Nash, M.S., & Mendez, A.J. (2007). A guideline-driven assessment of need for cardiovascular disease risk intervention in persons with chronic paraplegia. Archives of Physical Medicine & Rehabilitation88(6): 751-7. http://dx.doi.org/10.1016/j.apmr.2007.02.031
    Ozgurtas, T., et al. (2003). Do spinal cord injuries adversely affect serum lipoprotein profiles? Military Medicine168(7): 545-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12901464
    Ragnarsson, K.T. (2012). Medical rehabilitation of people with spinal cord injury during 40 years of academic practice. American Journal of Physical Medicine and Rehabilitation91(3): 231-42.
    Shah, P.K., Stevens, J.E., Gregory, C.M., Pathare, N.C., Jayaraman, A., Bickel, S.C., Bowden, M., et al. (2006). Lower-extremity muscle cross-sectional area after incomplete spinal cord injury. Archives of Physical Medicine & Rehabilitation87(6):772-8.    Solomonow, M., et al. (1997). Reciprocating gait orthosis powered with electrical muscle stimulation (RGO II). Part II: Medical evaluation of 70 paraplegic patients. Orthopedics20(5): 411-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9172248
    Spungen, A.M., et al. (2003). Factors influencing body composition in persons with spinal cord injury: a cross-sectional study. Journal of Applied Physiology95(6): 2398-407.http://jap.physiology.org/cgi/content/abstract/95/6/2398
    Stewart, B.G., et al. (2004). Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury. Muscle & Nerve30(1): 61-8.http://dx.doi.org/10.1002/mus.20048
    Svircev, J.N. (2009). Cardiovascular disease in persons with spinal cord dysfunction-An update on select topics. Physical Medicine and Rehabilitation Clinics of North America20(4): 737-747.
    Szlachcic, Y., et al. (2001). The effect of dietary intervention on lipid profiles in individuals with spinal cord injury. Journal of Spinal Cord Medicine24(1): 26-29. http://www.ncbi.nlm.nih.gov/pubmed/11587431
    Teasell, R.W., Hsieh, J.T., Aubut, J.A.L., Eng, J.J., Krassioukov, A., & Tu., L. (2010). Venous thromboembolism after spinal cord injury. Archives of Physical Medicine and Rehabilitation90(92): 193-200).
    Waddimba, A.C., Jain, N.B., Stolzmann, K. Gagnon, D.R., Burgess, J.F., Jr., Kazis, L.E., et al. (2009). Predictors of cardiopulmonary hospitalization in chronic spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90(2): 193-200.
    Wahman, K., et al. (2010). Cardiovascular disease risk factors in persons with paraplegia: the Stockholm spinal cord injury study. Journal of Rehabilitation Medicine42(3): 272-8.http://dx.doi.org/10.2340/16501977-0510
    Wahman, K., Nash, M.S., Lewis, J.E., Seiger, A., & Levi, R. (2011). Cardiovascular disease risk and the need for prevention after paraplegia determined by conventional multifactorial risk models: The Stockholm spinal cord injury study. Rehabilitation Medicine43(3): 237-242.