Early Identification of Cardiovascular Diseases in People With Spinal Cord Injury: Key Information for Primary Care Providers

Burden of Cardiovascular Risk in Individuals With Spinal Cord Injury and Its Association With Rehabilitation Outcomes: Results From the Swiss Spinal Cord Injury Cohort

OBJECTIVES

The aims of the study are to determine the cardiovascular risk burden rehabilitation discharge and to explore the association between recovery during rehabilitation and cardiovascular disease risk profile.

METHODS

We included adults without cardiovascular disease admitted for rehabilitation. We evaluated rehabilitation outcomes on admission and discharge. Cardiovascular disease risk profile was assessed by Framingham risk score, high-density lipoprotein, and fasting glucose level.

RESULTS

We analyzed data from 706 participants (69.6% men) with a median age of 53.5 yrs. The median time since injury was 14 days, and the admission length was 5.2 months. Majority had paraplegia (53.3%) and motor incomplete injury (53.7%). One third of the cohort had high cardiovascular risk profile before discharge. At discharge, poorer anthropometric measures were associated with higher Framingham risk score and lower high-density lipoprotein levels. Individuals with higher forced vital capacity (>2.72 l) and peak expiratory flow (>3.4 l/min) had 0.16 mmol/l and 0.14 mmol/l higher high-density lipoprotein compared with those with lower respiratory function, respectively. Individuals with higher mobility score (>12.5) and functional independence score (>74) had 0.21 and 0.18 mmol/l higher high-density lipoprotein compared with those with lower scores.

CONCLUSIONS

There is high cardiometabolic syndrome burden and cardiovascular disease risk profile upon rehabilitation discharge. Higher respiratory function, mobility, and overall independence were associated with better cardiovascular disease risk profile, although with study design limitations and short follow-up. Future studies should explore whether rehabilitation outcomes could be used to prioritize screening.

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CME OBJECTIVES

Upon reading this journal article, the reader is expected to: (1) Determine the burden of cardiometabolic disease in the early phase of spinal cord injury (SCI); (2) Differentiate the proposed SCI cutoff for high-risk obesity from the able-bodied population; and (3) Increase physicians' acuity for detecting cardiometabolic disease in their practice.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Cardiometabolic risk profiling during spinal cord injury rehabilitation: A longitudinal analysis from Swiss Spinal Cord Injury cohort (SwiSCI)

BACKGROUND

Early screening is important in individuals with spinal cord injury (SCI) as they were deemed high-risk for cardiometabolic diseases. Few studies explored changes in cardiometabolic risk profile in the early phase of the injury. Thus, it remains unclear how early the cardiometabolic status deteriorates after injury.

OBJECTIVE

We determined the longitudinal changes in the cardiometabolic risk profile and examined the association between injury characteristics and cardiometabolic status in subacute SCI.

SETTING

Multicenter Swiss Spinal Cord Injury Cohort.

PARTICIPANTS

Adults with traumatic SCI without history of cardiovascular disease or type 2 diabetes.

MAIN OUTCOME MEASURES

Blood pressure (BP), lipid profile, fasting glucose, waist circumference (WC), weight, body mass index (BMI) and Framingham risk score (FRS) were compared across time and according to the injury characteristics.

RESULTS

We analyzed the data of 258 individuals with traumatic SCI (110 tetraplegia and 148 paraplegia, 122 motor complete and 136 incomplete). The median age was 50 years (IQR 32-60), with 76.36% (n=197) of the population being male. The median rehabilitation duration was 5.5 months (IQR 3.2-7.1). At admission to rehabilitation, fully-adjusted linear regression models showed higher baseline weight (β 0.06, 95% CI 0.005, 0.11), systolic BP (β 0.05, 95% CI 0.008, 0.09), diastolic BP (β 0.05 95% CI 0.004, 0.10), and triglycerides (β 0.27 95% CI 0.13, 0.42) in paraplegia than tetraplegia. Systolic BP, diastolic BP, HDL-C were higher in incomplete than complete injury. In our main analysis, we observed an increase in cholesterol and HDL-C and lipid ratio when comparing the beginning and end of rehabilitation. Individuals with paraplegia had a higher increase in BMI than tetraplegia, while no differences in other cardiometabolic risk factors were detected when comparing motor incomplete and complete injury. Trajectories of each participant showed that the majority of individuals with SCI decreased FRS score at follow-up compared to baseline and no significant changes in prevalence of cardiometabolic syndrome were observed. At discharge, one-third of study participants were classified as moderate to high risk of CVD, 64% were overweight, and 39.45% had cardiometabolic syndrome.

CONCLUSION

We observed a modest improvement in lipid profile and FRS during the first inpatient rehabilitation hospitalization. Injury characteristics, such as level and completeness, were not associated with changes in cardiometabolic risk factors in the subacute phase of the injury. Despite this, a significant proportion of study participants remained at risk of cardiometabolic disease at discharge, suggesting that early cardiometabolic preventive strategies may be initiated as early as during the first inpatient rehabilitation hospitalization. This article is protected by copyright. All rights reserved.

Preventative Services Use and Risk Reduction for Potentially Preventative Hospitalizations among People with Traumatic Spinal Cord Injury

OBJECTIVE

To examine the risk of potentially preventable hospitalizations (PPHs) for adults (18 years or older) with traumatic spinal cord injury (TSCI) to identify the most common types of preventable hospitalizations and their associative risk factors.

DESIGN

Cohort study.

SETTING

Using 2007-2017 U.S. claims data from the Optum Clinformatics Data Mart, we identified adults (18 years or older) with diagnosis of TSCI (n=5380). Adults without TSCI diagnosis were included as controls (n=1,074,729). Using age and sex, we matched individuals with and without TSCI (n=5173) with propensity scores to address potential selection bias. Generalized linear regression was applied to examine the risk of TSCI on PPHs. Models were adjusted for age; sex; race and ethnicity; Elixhauser comorbidity count; any cardiometabolic, psychological, and musculoskeletal chronic conditions; U.S. Census Division; socioeconomic variables; and use of certain preventative care services. Adjusted odds ratios were compared within a 4-year follow-up period.

PARTICIPANTS

Adults with and without TSCI (N=5,173).

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

Any PPH and specific PPHs RESULTS: Adults with TSCI had higher risk for any PPH (odds ratio [OR], 1.67; 95% CI,1.20-2.32), as well as PPHs because of urinary tract infection (UTI) (OR, 3.78; 95% CI, 2.47-5.79), hypertension (OR, 3.77; 95% CI, 1.54-9.21), diabetes long-term complications (OR, 2.54; 95% CI, 1.34-4.80), and pneumonia (OR, 1.71; 95% CI. 1.21-2.41). Annual wellness visit was associated with reduced PPH risk compared with cases and controls without annual wellness visit (OR, 0.57; 95% CI, 0.46-0.71) and among people with TSCI (OR, 0.69; 95% CI, 0.55-0.86) compared with cases without annual wellness visit.

CONCLUSIONS

Adults with TSCI are at a heightened risk for PPH. They are also more susceptible to certain PPHs such as UTIs, pneumonia, and heart failure. Encouraging the use of preventative or health-promoting services, especially for respiratory and urinary outcomes, may reduce PPHs among adults with TSCI.

Effects of robotic-assisted gait training on the central vascular health of individuals with spinal cord injury: A pilot study

Objective: To investigate the effect of a short-term, robotic-assisted (exoskeleton) gait training (RGT) program on central and peripheral hemodynamic measures in patients with spinal cord injury (SCI).Design: Parallel group, non-randomized trial with before (baseline) and after (follow-up) assessments.Setting: Single-center, community-based neuro-physiotherapy practice.Participants: Twelve individuals with SCI (ASI A to C).Interventions: Participants completed either a 5-day RGT program plus physiotherapy (n = 6), or a usual care physiotherapy only program (control group; n = 6). The RGT program consisted of daily 60-min physiotherapy and 90-min of RGT. Outcome measures were measured before and after the rehabilitation program.Main outcome measure(s): The primary outcome measure was arterial wave reflection (Augmentation index [AIx]), with central and peripheral blood pressures also reported. Data are presented as mean (SD) and effect sizes (partial eta squared; η2p).Results: There was a significant reduction in AIx (30 ± 18-21 ± 15%; η2p=0.75) and mean arterial pressure (89 ± 11-82 ± 10 mmHg; η2p=0.47) following completion of the RGT program (both P < 0.05). There were no changes in these measures for the control group. Although not significantly different, medium to large effects were observed in favor of RGT for all other central and peripheral measures (η2p=0.06-0.21), except for heart rate and pulse pressure (η2p<0.04).Conclusions: RGT using an exoskeleton is a promising therapy for improving cardiovascular health in patients with SCI. Specifically, this study indicates decreased arterial wave reflection and supports the need for larger randomized controlled trials.Trial Registration: Clinical trials Registry (https://clinicaltrials.gov/; NCT03611803).

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Systolic and diastolic function in chronic spinal cord injury

Individuals with spinal cord injury develop cardiovascular disease more than age-matched, non-injured cohorts. However, progression of systolic and diastolic dysfunction into cardiovascular disease after spinal cord injury is not well described. We sought to investigate the relationship between systolic and diastolic function in chronic spinal cord injury to describe how biological sex, level, severity, and duration of injury correlate with structural changes in the left ventricle. Individuals with chronic spinal cord injury participated in this study (n = 70). Registered diagnostic cardiac sonographers used cardiac ultrasound to measure dimensions, mass, and systolic and diastolic function of the left ventricle. We found no significant relationship to severity or duration of injury with left ventricle measurements, systolic function outcome, or diastolic function outcome. Moreover, nearly all outcomes measured were within the American Society of Echocardiography-defined healthy range. Similar to non-injured individuals, when indexed by body surface area (BSA) left ventricle mass [-14 (5) g/m2, p < .01], end diastolic volume [-6 (3) mL/m², p < .05], and end systolic volume [-4 (1) mL/m², p < .01] were significantly decreased in women compared with men. Likewise, diastolic function outcomes significantly worsened with age: E-wave velocity [-5 (2), p < .01], E/A ratio [-0.23 (0.08), p < .01], and e’ velocity [lateral: -1.5 (0.3) cm/s, p < .001; septal: -0.9 (0.2), p < .001] decreased with age while A-wave velocity [5 (1) cm/s, p < .001] and isovolumic relaxation time [6 (3) ms, p < .05] increased with age. Women demonstrated significantly decreased cardiac size and volumes compared with men, but there was no biological relationship to dysfunction. Moreover, individuals were within the range of ASE-defined healthy values with no evidence of systolic or diastolic function and no meaningful relationship to level, severity, or duration of injury. Decreases to left ventricular dimensions and mass seen in spinal cord injury may result from adaptation rather than maladaptive myocardial remodeling, and increased incidence of cardiovascular disease may be related to modifiable risk factors.