risk analysis for cardiovascular disease after spinal cord injury ann m. spungen, edd associate...
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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
s in
SC
I:S
tud
ies
in S
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
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
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
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.
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)
Lipid ProfileLipid Profile
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
Lipid ProfileLipid Profile
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.
Lipid ProfileLipid Profile
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.
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
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.
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 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