risk analysis for cardiovascular disease after spinal cord injury ann m. spungen, edd associate...

Risk Analysis for Risk Analysis for Cardiovascular Disease Cardiovascular Disease after Spinal Cord Injuryafter Spinal Cord Injury

Ann M. Spungen, EdDAnn M. Spungen, EdDAssociate Professor of Medicine and Rehabilitation Medicine, Associate Professor of Medicine and Rehabilitation Medicine,

Mount Sinai School of Medicine, NYMount Sinai School of Medicine, NYAssociate Director VA RR&D Center of Excellence for the Associate Director VA RR&D Center of Excellence for the

Medical Consequences of SCIMedical Consequences of SCICo-Chair VA CS #535Co-Chair VA CS #535

The State of the Science ConferenceThe State of the Science ConferenceJuly 17, 2007July 17, 2007

National Rehabilitation HospitalNational Rehabilitation HospitalRRTC on Spinal Cord InjuryRRTC on Spinal Cord Injury

OutlineOutline

Risk factor description Risk factor description (AHA, NCEP)(AHA, NCEP)

Assessments for lipids, DM, IR, HTNAssessments for lipids, DM, IR, HTN Traditional, non traditional or Traditional, non traditional or

emergingemerging

Risk factor treatment goals and Risk factor treatment goals and guidelinesguidelines

Risk factors in SCI (data)Risk factors in SCI (data)

American Heart Association American Heart Association (AHA) Risk Factors for CVD(AHA) Risk Factors for CVD

Non ModifiableNon Modifiable Increasing ageIncreasing age Male genderMale gender HeredityHeredity

Other ContributorsOther Contributors StressStress Excess alcoholExcess alcohol

ModifiableModifiable

SmokingSmoking

High cholesterolHigh cholesterol

High blood pressureHigh blood pressure

Physical inactivityPhysical inactivity

ObesityObesity

Diabetes mellitusDiabetes mellitus

AHA AHA ModifiableModifiable RFs for CVDRFs for CVD SmokingSmoking

Independent RFIndependent RF 2-4x >risk of CHD2-4x >risk of CHD Persons w/CHD, 2x risk Persons w/CHD, 2x risk

for sudden deathfor sudden death Neg. acts on other RFs Neg. acts on other RFs

(Cholesterol, BP and DM)(Cholesterol, BP and DM) Cigar/pipe also have Cigar/pipe also have

>risk of death>risk of death Secondhand smoke Secondhand smoke

exposure exposure >risk of CHD >risk of CHD High CholesterolHigh Cholesterol

>Serum cholesterol; >Serum cholesterol; >risk for CHD>risk for CHD

In presence of HTN or In presence of HTN or Smk, risk for CHD is Smk, risk for CHD is amplifiedamplified

High Blood PressureHigh Blood Pressure work of the heart work of the heart

stiffeningstiffening risk of stroke, heart risk of stroke, heart

attack, kidney failure, & attack, kidney failure, & CHFCHF

risk w/obesity, smk, high risk w/obesity, smk, high cholesterol, and/or DMcholesterol, and/or DM

Physical InactivityPhysical Inactivity PA, >risk of heart and PA, >risk of heart and

vessel diseasevessel disease ObesityObesity

>Body fat (waist), >risk of >Body fat (waist), >risk of HDHD

risk of DMrisk of DM Diabetes MellitusDiabetes Mellitus

¾ of all DM die of some ¾ of all DM die of some form of heart or vessel form of heart or vessel diseasedisease

AHA Risk Factors for CVDAHA Risk Factors for CVD Non ModifiableNon Modifiable

Increasing ageIncreasing age 83% CHD deaths are in 83% CHD deaths are in ≥≥65y65y Older ages, women who have Older ages, women who have

heart attacks are more likely to heart attacks are more likely to die than mendie than men

GenderGender Men >risk of heart attack and Men >risk of heart attack and

occur earlier in lifeoccur earlier in life Post menopause Women’s Post menopause Women’s

death rate from CHD death rate from CHD ↑↑, not , not equal to men’sequal to men’s

Heredity Heredity (Race/Ethnicity)(Race/Ethnicity) >Risk in children of parents >Risk in children of parents

w/HDw/HD >Risk in African, Mexican, >Risk in African, Mexican,

Native, Hawaiian, and some Native, Hawaiian, and some Asian Americans than in Asian Americans than in CaucasiansCaucasians

Other ContributorsOther Contributors StressStress

Noted relationship Noted relationship w/CHDw/CHD

May cause May cause worsening of other worsening of other RFs (i.e.RFs (i.e.smoking, smoking, overeating, etc.)overeating, etc.)

Excess alcoholExcess alcohol Women (1 drink/d) Women (1 drink/d)

and Men (2 drinks/d)and Men (2 drinks/d) Can raise BPCan raise BP Increase TGsIncrease TGs Irregular HBsIrregular HBs Add to obesityAdd to obesity

Non Traditional or Emerging Non Traditional or Emerging Risk Factors for CHDRisk Factors for CHD

Insulin resistanceInsulin resistance

Plasma homocysteinePlasma homocysteine

C-reactive proteinC-reactive protein Lipoprotein (a) Lipoprotein (a)

Small, dense LDL particles Small, dense LDL particles

Prothrombic factorsProthrombic factors

Risk Factor AssessmentRisk Factor Assessment

Lipid ProfileLipid Profile

Oral Glucose Oral Glucose ToleranceTolerance

Blood Blood Pressure Pressure AssessmentAssessment

ScreeningScreening Medical HxMedical Hx Age, GenderAge, Gender SmokingSmoking ObesityObesity Family HxFamily Hx Physical Physical

ActivityActivity Stress/lifestyleStress/lifestyle

ATP III Classification ofATP III Classification ofLDL Cholesterol LDL Cholesterol (mg/dL)(mg/dL)

LDL Cholesterol<100

100-129130-159160-189

≥190

HDL Cholesterol<40≥60

ClassificationOptimalNear or above optimalBorderline highHighVery high

LowHigh

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

ATP IIIATP IIIRisk Categories & LDL-C GoalsRisk Categories & LDL-C Goals

*Almost all people with 0-1 risk factor have a 10-year risk <10%; thus, Framingham risk calculations are not necessary.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

NLEC2002, www.lipidhealth.org

Risk CategoryRisk Category

CHD and CHD risk CHD and CHD risk equivalents orequivalents or

10-year risk >20%10-year risk >20%

≥≥2 risk factors or2 risk factors or10-year risk ≤20%10-year risk ≤20%

0-1 risk factor*0-1 risk factor*

LDL Goal LDL Goal (mg/dL)(mg/dL)

<100<100

<130<130

<160<160

Diagnostic Criteria for Disorders Diagnostic Criteria for Disorders of Carbohydrate Metabolismof Carbohydrate Metabolism

Report of the Expert Committee on the Diagnosis and Classification of Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus:Diabetes Mellitus: Diabetes Care Diabetes Care 20:1183-1197, 199720:1183-1197, 1997. . **Updated from 110, Updated from 110, Diabetes Care Diabetes Care 20032003

Normal Normal (NGT)(NGT)

Impaired Impaired (IGT)(IGT)

Diabetic Diabetic (DM)(DM)

FPGFPG(mg/dL)(mg/dL)

<100<100

100100**-125-125

≥≥126126

OGTTOGTT

120 min120 min(mg/dL)(mg/dL)

<140<140

140-199140-199

≥≥200200

Assessment of Risk Factor Assessment of Risk Factor AnalysisAnalysis

Framingham Point Scores Framingham Point Scores (separate for gender)(separate for gender)

Age categoriesAge categories Total-C by Age CatTotal-C by Age Cat Smoker / NonsmokerSmoker / Nonsmoker HDL-c categoriesHDL-c categories SBP categoriesSBP categories

Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, Evaluation, and treatment of High Blood Cholesterol in Adults (adult treatment Panel III). JAMA. 285(19), 2001.

http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Stu

die

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CI:

Body Comp Spungen AM, et al. J Appl Physiol, 2000. Spungen AM, et al. J Appl Physiol, 2003.

Oral Glucose Tolerance Bauman WA and Spungen AM. Metabolism. 1994; 43:749-756. Bauman WA, et al. Spinal Cord. 1999; 37: 765-771.

Lipid Profile Bauman WA, et al. Spinal Cord. 1998; 36:13-17. Bauman WA, et al. Spinal Cord. 1999; 37:485-493. La Porte RE et al. Lancet. 1:1212-1213 1983.

Homocysteine Bauman WA, et al. J Spinal Cord Medicine. 2001; 24:81-86.

C-Reactive Protein Lee MY, et al. JSCM 28:20-25, 2005.

Risk Factors for CHD Bauman WA and Spungen AM, Top Spinal Cord Inj Rehabil;

12:35-53. Nash MS Arch Phys Med Rehabil.Arch Phys Med Rehabil. 88:751-757, 2007 88:751-757, 2007

Total Body Lean Tissue Loss with Total Body Lean Tissue Loss with Duration of Injury in the SCI TwinsDuration of Injury in the SCI Twins

Duration of Injury (y)Duration of Injury (y)

Intr

apai

r D

iff

(kg

)In

trap

air

Dif

f (k

g)

-30

-25

-20

-15

-10

-5

0

5

0 5 10 15 20 25 30

R2 = 0.44, P<0.01Slope = -0.488 ±0.16

TO

TA

L B

OD

Y P

erce

nt

Fat

Body Mass Index (kg/m2)

0

10

20

30

40

50

60

10 15 20 25 30 35 40 45

SCI

Control

30

40

50

60

70

80

90

100T

OT

AL

BO

DY

Per

cen

t L

ean

10 20 30 40 50 60 70 80AGE (y)

Tetra

Para

Control

Body Composition in SCIBody Composition in SCI

Spungen AM, Adkins RH, Stewart CA, Wang J, Pierson Jr RN, Waters RL, Bauman WA. Factors influencing Spungen AM, Adkins RH, Stewart CA, Wang J, Pierson Jr RN, Waters RL, Bauman WA. Factors influencing body composition in persons with spinal cord injury: A cross-sectional study. body composition in persons with spinal cord injury: A cross-sectional study. J Appl Physiol,J Appl Physiol, 2003. 2003.

Tot

al B

ody

Per

cen

t F

at

Body Mass Index (kg/m2)

0

10

20

30

40

50

60

10 15 20 25 30 35 40 45

SCI

Controls

The Relationship of Percent Fat with Body Mass Index

Spungen et al., J Appl Physiol 95:2398-2407, 2003

Body Composition SummaryBody Composition Summary

Persons with SCI have:Persons with SCI have: lower amounts of lean body masslower amounts of lean body mass higher amounts of percent fathigher amounts of percent fat loose lean tissue mass with continued loose lean tissue mass with continued

duration of injuryduration of injury loose lean tissue mass at a greater loose lean tissue mass at a greater

rate over age than the general rate over age than the general population population

Oral Glucose Tolerance in Oral Glucose Tolerance in Veterans with or without SCIVeterans with or without SCI

Bauman WA and Spungen AM. Metabolism. 43: 749-756, 1994

Relationship of Age with Relationship of Age with Glucose Tolerance in VeteransGlucose Tolerance in Veterans

Bauman WA and Spungen AM. Metabolism. 43: 749-756, 1994

Oral Glucose Tolerance in Oral Glucose Tolerance in Non VETS with SCINon VETS with SCI

201 SCI201 SCI 169 Men, 32 Women169 Men, 32 Women 114 Latino, 54 White, 28 Afric Amer114 Latino, 54 White, 28 Afric Amer 56 Comp Tetra, 25 Inc Tetra, 84 Comp Para, 56 Comp Tetra, 25 Inc Tetra, 84 Comp Para,

36 Inc Para36 Inc Para Total Study Group meanTotal Study Group meanSEM (range)SEM (range)

Age (y)Age (y) 39 39 0.8 (20 - 73) 0.8 (20 - 73) DOI (y)DOI (y) 13 13 0.7 (1 - 43) 0.7 (1 - 43) BMI (kg/mBMI (kg/m22)) 25 25 0.4 0.4 TB %Fat (%)TB %Fat (%) 34 34 0.9 0.9

Bauman WA, Adkins RH, Spungen AM, Waters RL. The effect of residual neurological deficit on oral Bauman WA, Adkins RH, Spungen AM, Waters RL. The effect of residual neurological deficit on oral glucose tolerance in persons with chronic spinal cord injury. glucose tolerance in persons with chronic spinal cord injury. Spinal CordSpinal Cord. 1999; 37: 765-771.. 1999; 37: 765-771.

Oral Glucose Tolerance inOral Glucose Tolerance inNon VETS with SCINon VETS with SCI

59%59%n=118n=118

28%28%n=56n=56

13%13%n=27n=27

NormalNormalIGTIGT

DMDMIGT or DMIGT or DM

Comp TetraComp Tetra 73%*73%*

Inc Tetra 44%Inc Tetra 44%

Comp Para 24%Comp Para 24%

Inc Para 31%Inc Para 31%

**22(6)(6)=36.9, p<0.0001=36.9, p<0.0001


Oral Glucose Tolerance inOral Glucose Tolerance inNon VETS with SCINon VETS with SCI

Percent with hyperinsulinemia Percent with hyperinsulinemia during the OGTTduring the OGTT

53% Tetra 53% Tetra (mostly Complete Tetra)(mostly Complete Tetra)

37% Para37% Para

46% Males 46% Males (*(*sig.sig. higher peak and higher peak and insulin insulin with similar glucose levels)with similar glucose levels)

31% Females31% FemalesBauman WA, Adkins RH, Spungen AM, Waters RL. The effect of residual neurological deficit on oral Bauman WA, Adkins RH, Spungen AM, Waters RL. The effect of residual neurological deficit on oral glucose tolerance in persons with chronic spinal cord injury. glucose tolerance in persons with chronic spinal cord injury. Spinal CordSpinal Cord. 1999; 37: 765-771.. 1999; 37: 765-771.

Additional findings inAdditional findings inNon VETS with SCINon VETS with SCI

Peak GlucosePeak Glucose correlated with: correlated with: Highest level of lesion Highest level of lesion Older age at time of injuryOlder age at time of injury Increased TB %fatIncreased TB %fat

Peak InsulinPeak Insulin correlated with: correlated with: Male genderMale gender Increased TB %fatIncreased TB %fat


CHO Metabolism SummaryCHO Metabolism Summary Increased prevalence of IGT and DMIncreased prevalence of IGT and DM The greater the ND, the worse the CHO The greater the ND, the worse the CHO

metabolismmetabolism Peak Glucose is independently related to Peak Glucose is independently related to

%fat, ND, age at time of injury, and male %fat, ND, age at time of injury, and male gendergender

HyperinsulinemiaHyperinsulinemia: >50% Tetra and >30% Para: >50% Tetra and >30% Para

OGTT OGTT ↔↔ to diagnose early disease (IGT, to diagnose early disease (IGT, mild DM, and hyperinsulinemia)mild DM, and hyperinsulinemia)


541 SCI541 SCI 247 Tetra, 294 Para247 Tetra, 294 Para 156 ComT, 91 IncT, 206 ComP, 88 IncP156 ComT, 91 IncT, 206 ComP, 88 IncP 111 Latino, 86 White, 50 Afric Amer111 Latino, 86 White, 50 Afric Amer 221 Men, 26 Women221 Men, 26 Women

Total Study Group meanTotal Study Group meanSEM SEM Age (y)Age (y) 38 38 0.7 0.7 DOI (y)DOI (y) 13 13 0.6 0.6 BMI (kg/mBMI (kg/m22)) 24.3 24.3 0.31 0.31

Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization associated with an abnormal lipoprotein profile? Observations in a diverse cohort. associated with an abnormal lipoprotein profile? Observations in a diverse cohort. Spinal CordSpinal Cord. . 1999; 37:485-493.1999; 37:485-493.

3030

3535

4040

4545

5050

TetraTetraCompleteComplete

TetraTetraIncompleteIncomplete

ParaParaCompleteComplete

ParaParaIncompleteIncomplete


In 541 NonVets with SCI, In 541 NonVets with SCI, 29% had serum HDL level29% had serum HDL level

<35 mg/dL<35 mg/dL

Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization associated with an Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization associated with an abnormal lipoprotein profile? Observations in a diverse cohort. abnormal lipoprotein profile? Observations in a diverse cohort. Spinal CordSpinal Cord. 1999; 37:485-493.. 1999; 37:485-493.

Additional Lipid ValuesAdditional Lipid Values

LDL LDL 130 130 (m/dL)(m/dL)

TC/HDLTC/HDL>4.5>4.5

CompCompTetraTetra

(n=156)(n=156)

51% 51%

55%55%

CompCompParaPara

(n=206)(n=206)

49%49%

48%48%

IncompIncompTetraTetra(n=91)(n=91)

42%42%

52%52%

IncompIncompParaPara

(n=88)(n=88)

32%32%

44%44%

TC=total cholesterol; HDL=high density lipoprotein cholesterolTC=total cholesterol; HDL=high density lipoprotein cholesterol

Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization associated Bauman WA, Adkins RH, Spungen AM, Maloney P, Gambino R, Waters RL. Is immobilization associated with an abnormal lipoprotein profile? Observations in a diverse cohort. with an abnormal lipoprotein profile? Observations in a diverse cohort. Spinal CordSpinal Cord. 1999; 37:485-493.. 1999; 37:485-493.



TotalTotal

MenMenWomenWomen

WhiteWhiteAfric AmerAfric AmerLatinoLatino

SCISCI320320

2332338787

14914988888383

ControlControl303303

2442445959

16916987874747

Comparison of Serum HDL Cholesterol & Comparison of Serum HDL Cholesterol & Triglycerides Among Ethnic SubgroupsTriglycerides Among Ethnic Subgroups

**PP<0.0001<0.0001

**PP<0.05<0.05


Lipid Metabolism in SCI Lipid Metabolism in SCI SummarySummary

Significantly lower HDLsSignificantly lower HDLs

Greater decrease in HDLs with Greater decrease in HDLs with increasing neurological deficitincreasing neurological deficit

African Americans with SCI have a African Americans with SCI have a similar lipid profile to the general similar lipid profile to the general populationpopulation

Significance of Plasma Significance of Plasma Homcysteine levelsHomcysteine levels

A vasotoxic amino acidA vasotoxic amino acid Increased concentrations are Increased concentrations are

caused by genetic mutations, caused by genetic mutations, vitamin deficiencies, renal and other vitamin deficiencies, renal and other diseases, various drugs, and diseases, various drugs, and increasing ageincreasing age

Increased levels are associated with Increased levels are associated with increased risk of CHDincreased risk of CHD

Plasma Homocysteine Levels Plasma Homocysteine Levels in Persons with SCI (n=845)in Persons with SCI (n=845)

HCYHCY TotalTotal MenMen WomenWomen((µµmol/L)mol/L) % (N) % (N) % (n) % (n) % (n) % (n)

≤ ≤ 1414 56 (474)56 (474)> 15-19*> 15-19* 33 (282)33 (282) 37 (264) 37 (264) 15 (18)15 (18)> 20> 20†† 11 (89)11 (89) 12 (87) 12 (87) 2 (2) 2 (2)

Mortality ratios: *2.8; Mortality ratios: *2.8; † † 4.54.5

Bauman et al., J Spinal Cord Med. 24:81-86, 2001

Significance of C-reactive Significance of C-reactive Protein (CRP)Protein (CRP)

General marker of inflammationGeneral marker of inflammation Measures the concentration of a Measures the concentration of a

protein in serum that indicates protein in serum that indicates acute inflammation acute inflammation

Associated with increased risk of Associated with increased risk of CHDCHD

C-Reactive Protein in SCIC-Reactive Protein in SCIRISKRISK

LowestLowest

MildMild

ModerateModerate

HighHigh

HighestHighest

CountCount

1616

1313

1616

1515

1717

Lee Et al., JSCM 28:20-25, 2005

mg/Lmg/L

<0.7<0.7

0.7-1.10.7-1.1

1.2-1.91.2-1.9

2.0-3.82.0-3.8

3.9-15.03.9-15.0

21 %21 %

17 %17 %

21 %21 %

19 %19 %

22 %22 %

* Those with fasting insulin resistance were associated with a two-fold increase in CRP levels.

Homocysteine and Homocysteine and C-Reactive Protein SummaryC-Reactive Protein Summary

44% of SCI patients studied in a 44% of SCI patients studied in a large sample had a homocysteine large sample had a homocysteine level associated with an increased level associated with an increased mortality ratiomortality ratio

62% of SCI pts studied had 62% of SCI pts studied had moderate to high CRP levelsmoderate to high CRP levels

Risk Factor Analysis Study Risk Factor Analysis Study in SCIin SCI

Bauman WA and Spungen AM. Topics in Spinal Cord Inj Rehabil. 12:35-53, 2007.

Risk Factors by LDL Tx GoalRisk Factors by LDL Tx Goal

Bauman WA and Spungen AM. Topics in Spinal Cord Inj Rehabil. 12:35-53, 2007.

10

15

20

25

30

35

40

45C

ou

nt

10

20

30

40

50

60

70

80

90

Co

un

t

080 100 120 140 160 180 200 220 240 260 280 300

TC

5

0 100 200 300 400 500 600 700

TG

0 010 20 30 40 50 60 70 80 90 100 110

HDL

10

20

30

40

50

60

70

80

90

20 40 60 80 100 120 140 160 180 200 220

LDL

0

5

10

15

20

25

30

35

40

45

51±13

196±38 119±34

148±86

38±12

121±33

124±83

185±38

Risk Factors Study: SCI and NonSCIRisk Factors Study: SCI and NonSCI

HDL cholesterol <40 mg/dL: 63% HDL cholesterol <40 mg/dL: 63% HDL cholesterol <35 mg/dL: 44%HDL cholesterol <35 mg/dL: 44%HDL cholesterol <30 mg/dL: 19%HDL cholesterol <30 mg/dL: 19%

HDL Cholesterol in the Total HDL Cholesterol in the Total GroupGroup

Mean HDL cholesterol: 38 ±12 mg/dLMean HDL cholesterol: 38 ±12 mg/dL

Bauman WA and Spungen AM.Bauman WA and Spungen AM. Topics in Spinal Cord Inj Rehabil. Topics in Spinal Cord Inj Rehabil. 12:35-53, 2007. 12:35-53, 2007.

Assessment for Risk for CHD:Assessment for Risk for CHD:Percent of SCI Subjects Needing InterventionPercent of SCI Subjects Needing Intervention

Risk CategoryRisk Category Total SCITotal SCI %Tx%Tx LDL GoalLDL Goal

CHD or EquivalentCHD or Equivalent 11%11% 8%8% < 100< 100

10-year risk >20%10-year risk >20% 4%4% 3%3% < 100< 100

≥≥2 Risk Factors2 Risk Factors

10-y Risk >20%10-y Risk >20% 42%42% 24%24% < 130< 130

10-y Risk 10-20%10-y Risk 10-20% 20%20% 4%4% < 130< 130

0 to 1 Risk Factor0 to 1 Risk Factor 27%27% 2%2% < 160< 160

41 % of the SCI population qualified for intervention by 41 % of the SCI population qualified for intervention by ATP III guidelines.ATP III guidelines.

Bauman WA and Spungen AM.Bauman WA and Spungen AM. Topics in Spinal Cord Inj Rehabil. Topics in Spinal Cord Inj Rehabil. 12:35-53, 2007. 12:35-53, 2007.

Summary of Risk Factor StudySummary of Risk Factor Study Highest Risk Highest Risk LDL goal <100mg/dLLDL goal <100mg/dL (7 of 222 S’s)

((10-y risk >20%) 4% by Framingham Point score 9% had CHD dx or vascular disease equivalent9% had CHD dx or vascular disease equivalent

BUT, silent disease may missed in asymptomatic/inactiveBUT, silent disease may missed in asymptomatic/inactive

17% DM 17% DM ((↑↑IGT?)IGT?) BUT, higher if included known diabeticsBUT, higher if included known diabetics

Moderate Risk Moderate Risk LDL goal <130mg/dL LDL goal <130mg/dL (58 of 222 S’s) 50% 10y risk of 10-20% by 50% 10y risk of 10-20% by Framingham Point

score 70% had 2 or more RFs70% had 2 or more RFs

Overall, 41% qualified for interventionOverall, 41% qualified for intervention

Risk Factor Analysis in SCI:Risk Factor Analysis in SCI: A guideline driven assessment of need for cardiovascular A guideline driven assessment of need for cardiovascular

disease risk intervention in persons with chronic paraplegiadisease risk intervention in persons with chronic paraplegia

Subjects: Subjects: 41 subjects with paraplegia 41 subjects with paraplegia

ASIA A & B: T6 to L1 and Age: 34±11 yearsASIA A & B: T6 to L1 and Age: 34±11 years

Main Outcome Measure: Main Outcome Measure: % of subjects qualifying for intervention Based on % of subjects qualifying for intervention Based on

ATP III guidelinesATP III guidelines Results: Results:

63% of subjects qualified for intervention63% of subjects qualified for intervention 76% had HDL cholesterol <40 mg/dL76% had HDL cholesterol <40 mg/dL 1/3 had hypertension1/3 had hypertension 34% had the metabolic syndrome34% had the metabolic syndrome

Conclusion: Conclusion: A high percentage of young, A high percentage of young, healthy persons with SCI are at risk for CVD & healthy persons with SCI are at risk for CVD & qualify for lipid-lowering interventionqualify for lipid-lowering intervention

Nash MS, et al. Nash MS, et al. Arch Phys Med Rehabil.Arch Phys Med Rehabil. 88:751-757, 2007 88:751-757, 2007

CommentaryCommentary HDL cholesterol levels in persons with SCI HDL cholesterol levels in persons with SCI

are frequency depressed and require are frequency depressed and require heightened scrutiny because they may heightened scrutiny because they may greatly increase risk due to extremely greatly increase risk due to extremely depressed values, requiring more intense depressed values, requiring more intense intervention.intervention.

Absence of activity and associated Absence of activity and associated symptoms of CVD in persons with SCI may symptoms of CVD in persons with SCI may result in incorrect stratification of CHD result in incorrect stratification of CHD risk, resulting in reduced appreciation of risk, resulting in reduced appreciation of risk.risk.

Conventional RFs should be identified and Conventional RFs should be identified and treated in persons with SCI according to treated in persons with SCI according to current standards of care for the general current standards of care for the general population.population.

Special thanks to:Special thanks to:

Department of Veterans Affairs:Department of Veterans Affairs: Rehabilitation, Research and Development Rehabilitation, Research and Development

Service, Washington, DCService, Washington, DC James J Peters VA Medical Center, Bronx, NYJames J Peters VA Medical Center, Bronx, NY

United Spinal Association (Formerly EPVA), United Spinal Association (Formerly EPVA), Jackson Heights, NYJackson Heights, NY

Rancho Los Amigos National Rehabilitation Rancho Los Amigos National Rehabilitation Center, Downey CACenter, Downey CA

The Kessler Institute of Rehabilitation, West The Kessler Institute of Rehabilitation, West Orange, NJOrange, NJ

Staff of the Staff of the VA RR&D Center of Excellence for the VA RR&D Center of Excellence for the

Medical Consequences of SCIMedical Consequences of SCI

risk analysis for cardiovascular disease after spinal cord injury ann m. spungen, edd associate...

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emerging risk factors

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heart attacks