Primary Care and Cardiovascular Health

People with SCI have a 2x higher risk of cardiovascular disease (CVD) than the general population.

Here’s why: 

  1. People with SCI have a greater prevalence of obesity than general population. Denervated muscles, loss of muscle mass, lower levels of physical activity, and limited access to physical activities in people with SCI all results in more obesity. The World Health Organization (WHO) estimates that globally, 1 in 3 women and 1 in 4 men do not meet physical activity levels required for health; research on people with SCI shows that more than 50% are inactive.
  2. People with SCI have lower energy expenditure, and thus lower energy/food requirements. Lower levels of physical activity, no movement in lower limbs, and a lower thermic effect of food result in decreased energy expenditure and energy needs, but many people with SCI do not decrease how much they eat.
  3. People with SCI are more likely to have higher central adiposity. Due to limited activity, loss of muscle mass, and lack of core muscle control, people with SCI are also 58% more likely to have more fat accumulation around their middle.
  4. People with SCI also tend to have impaired glucose tolerance, insulin resistance, and dyslipidemia. Due to altered sympathetic and parasympathetic nervous system functioning, people with SCI have also been shown to have higher rates of diabetes and lower levels of HDL-C.
  5. Leading causes of death in people with SCI used to be pulmonary or renal, but like the general population, cardiovascular disease (CVD) is now the leading cause of death.  But, the actual prevalence  may be still underestimated and on the rise. Lifetime prevalence for CVD in people with SCI is estimated at 30-50%, but may actually be as high as 60-70%, given asymptomatic cases.
  6. Acute cardiac events can be harder to detect in people with SCI because of impaired sensation and atypical presentation (chest pain may not occur, or if it does people with SCI might not feel it, but instead you may see spasticity, fainting, or shortness of breath)

Proactive treatment of risk factors for cardiovascular disease is essential for your patients with SCI.

Pay special attention to:

  1. Nutrition: Obesity has been estimated at 50-75% in the SCI population, and significant nutritional inadequacies are common. First Line Treatment – The Clinical Practice Guidelines in Nutrition for People with SCI’s only strong and imperative recommendations are that nutritional assessment be done for the prevention and treatment of obesity in people with SCI. The good ‘rules of thumb’ are to: encourage a ‘heart-healthy diet’ with <5% saturated fat, <2400 mg sodium, and a caloric reduction of 10-15% in people with tetraplegia, and of 5-10% in people with paraplegia (from pre-injury diet). Second line treatment: consider referral to a dietician/nutritionist, preferably with experience with SCI or other lower activity population, to ensure recommendations take into consideration SCI-specifics and norms for weight and body composition, and adjust energy level or implement weight management strategies as appropriate.
  2. Pharmacological management: Guidelines for high-risk patients apply to people with SCI for pharmacological management of hypertension, dyslipidemia and diabetes, but pharmacological management of obesity is contraindicated. SCI-specific recommendations have not yet been established for blood cholesterol or diabetes, so recommendations for higher-risk patients without SCI should be applied (e.g., Multisociety Guidelines on Management of Blood Cholesterol). For example, adults aged 40 or older with LDL greater than 70 mg/dL ought to be offered moderate intensity statins, and those with greater than 190 mg/dL higher intensity statins; barring major lifestyle changes, statin therapy must usually be continued for life. For diabetes or pre-diabetes management, HbA1c value of 5.7% or greater is diagnostic of pre-diabetes and 6.5% is indicative of frank diabetes -Metformin is the preferred first-line agent for treating someone with an HbA1c value of greater than 7%.
  3. Lifestyle management: Evidence-based guidelines recommend 150 minutes per week of moderate to vigorous aerobic activity, as well as 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, autonomic dysreflexia, thermal dysregulation, and increased pressure sore risk.
    • 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.
  4. Blood Pressure must be considered for overall health as well as for exercise prescription. 
    Blood pressure (BP) is commonly lower in people with SCI, particularly those with lesions above T7 (e.g., 100/60 mm Hg). However, they are prone to BP drops and spikes due to autonomic instability/interference and postural influences.
    ° Establish your patient’s baseline BP values when standing, sitting, and lying down. Measure blood pressure at every routine visit and/or at least annually to monitor any changes.
    ° Apply evidence-based guidelines for treating hypertension as per general population; for most, the threshold for initiating pharmacotherapy is >140/90 mm Hg. Patient characteristics and current medications must be considered when selecting an antihypertensive agent (e.g., diuretics and bladder management).
  5. Reduce the number of cardiometabolic risk factors to <3 if possible, including:
    a. Reduce body fat to achieve body mass index (BMI) ≤ 22 kg/m2 or waist circumference to <34 inches
    b. Reduce triglycerides to ≤ 150 mg/dL and increase HDL-C to ≥ 40 mg/dL
    c. Reduce fasting blood glucose to ≤ 100 mg/dL and/or HbA1c to < 7%
    d. Encourage exercise ≥ 150 minutes per week to increase energy expenditure sufficiently to achieve neutral of negative (fat loss) energy balance
    e. Encourage adoption of a heart-healthy diet with focus on fruits, vegetables, low-fat dairy, poultry, fish, legumes, and nuts to achieve neutral or negative (fat loss) energy balance
    f. Recommend limiting saturated fat to 5% to 6% of total caloric intake

Download Exercise Guidelines for People With SCI

For cardiorespiratory fitness and muscle strength benefits, adults with SCI should engage in:

  • At least 20 minutes of moderate to vigorous intensity aerobic exercise 2 times per week.
  • 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week.

For cardiometabolic health benefits, adults with SCI are suggested to engage in:

  • At least 30 minutes of moderate to vigorous intensity aerobic exercise 3 times per week.

Proactive screening is important for patients with SCI so that under-diagnosis, lack of sensation, and/or conservative treatment do not contribute to higher number of cardiovascular problems.  Screen for all cardiovascular risk factors at least annually.

Risk Factor
Details
Frequency
Blood Pressure (BP) Baseline BP will generally be lower for people with SCI (100/60 mmHg +/- 20).

It is important to establish your patient’s standing, sitting, and lying (supine) BP to establish their baseline and to properly monitor fluctuations.

 Each regular health care visit or at least annually
Waist Circumference and/or Body Mass Index (BMI) Waist circumference may be more accurate for assessing health, fitness, and adipose tissue in people with SCI.  Ideal = less than 34 inches.

BMI ideal for people with SCI is lower than general population = 22 or less kg/m2.

 Waist Circumference and/or BMI should be measured at least annually. 

Smoking, Physical Activity, and Diet should be discussed each regular health care visit. 
Triglycerides If your patient regularly eats more calories than they burn, they may have high triglycerides (hypertriglyceridemia)

Normal: Less than 150 milligrams per deciliter (mg/dL), or less than 1.7 millimoles per liter (mmol/L)
Borderline high: 150 to 199 mg/dL (1.8 to 2.2 mmol/L)
High: 200 to 499 mg/dL (2.3 to 5.6 mmol/L)
Very high: 500 mg/dL or above (5.7 mmol/L or above)

 A minimum of every 1 to 2 years for males age 45 and older, females age 55 and older (SCI = High Risk for CVD patient).

Note: Fasting prior to blood test is required for an accurate reading.
Blood Glucose Test and/or A1C test To diagnose diabetes or prediabetes, the percentages commonly used are:

Normal: A1C below 5.7%
Prediabetes: A1C between 5.7 – 6.4%
Diabetes: A1C of 6.5% or higher

 The American Diabetes Association recommends testing for prediabetes/risk for future diabetes for all people beginning at age 45 years. If tests are normal, it is reasonable to repeat testing at a minimum of 3-year intervals.

People with SCI should be tested more regularly if they have physical symptoms of blood sugar dysregulation (e.g., dizziness, fatigue, obesity) or if they are physically active less than 3 times per week.
Total Cholesterol, including low-density lipoprotein (LDL) and high-density lipoprotein (HDL)  Fasting lipid profile or at minimum high-density lipoprotein cholesterol (HDL-C) and triglycerides should be assessed annually, with diet, exercise, and statin or extended-release niacin prescribed to achieve target triglycerides ≤150 mg/dL and HDL-C ≥40 mg/dL. Guidelines for adults without SCI is every 4-6 years; therefore screening should be more often for your patients with SCI (accordingly) based on patient’s age and number of risk factors for CVD.

Sources: Heart-Health Screenings – American Heart Association, Hemoglobin A1C (HbA1c) Test, Triglycerides test

Reviewed by Dr. Rhonda Willms 02March2022.

A referral to a cardiologist should be considered in all patients with 3 or more risk factors for cardiovascular disease (who you have not been able to move to <3 risk factors despite a period of treatment time/surveillance)

  • If waist circumference is greater than 34 inches, or if body mass index (BMI) greater than 22 kg/m2
  • If triglycerides are greater than 150 mg/dL or HDL-C is less than 40 mg/dL
  • If fasting blood glucose is greater than 100 mg/dL and/or HbA1c is greater than 7%
  • If person exercises less than 150 minutes per week (moderate to vigorous)
  • If diet is not primarily comprised of fruits, vegetables, low-fat dairy, poultry, fish, legumes, and nuts, and saturated fats makes up more than 6% of total caloric intake.

Consider referral to a dietician/nutritionist, preferably with experience with SCI or other lower activity population, to ensure recommendations take into consideration SCI-specifics and norms for weight and body composition, and adjust energy level or implement weight management strategies as appropriate.

Consider referral to an exercise specialist with experience working with people with SCI or neurological disabilities. Patients should also consult with a health professional who is knowledgeable in the types and amounts of exercise appropriate for people with SCI. Individuals with a cervical or high thoracic injury should be aware of the signs and symptoms of autonomic dysreflexia during exercise.

Sources: Stillman et al. 2020 A Provider’s Guide to Vascular Disease, Dyslipidemia, and Glycemic Dysregulation in Chronic Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2020;26(3):203-208. SCI Nutrition Guidelines (2009), SCI Exercise Guidelines in English. 

Map of US SCI Model Systems Hospitals

Access to specialists (cardiology, physiatry) may be limited, particularly if you do not live in or near a major city.

Advanced screening re your patient’s cardiovascular functioning, health, and fitness may best be handled by a cardiologist, physiatrist, or exercise specialist with experience in SCI. These specialists will be essential for your patient’s health care team.

If you or your patients with SCI are not already connected, please try to gain access to a urologist or physiatrist near you. Refer to the list of SCI centers worldwide below:

(Please email SCIRE Professional if we do not have a list for your country)

Additional Resources:

Infoline at SCI-BC has peers (people with SCI) that are trained in Exercise Coaching for people with SCI. Contact via email (info@sci-bc.ca) or call the InfoLine at 1-800-689-2477 (Open M-F 9am-5pm PST).

ProActive SCI Intervention Toolkit: A step-by-step resource designed to help physiotherapists work with their clients with SCI to be physically active outside of the clinic. Found on SCI Action Canada website.

Exercise Guidelines for People With SCI (in multiple languages)

Movement For All Lab – Dr. Jasmin Ma, PhD

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For Clinical Practice Guideline recommendations based on your patient’s level of injury and specific complaint, click here for the CAN-SCIP Coach App.

For more information see our Cardiovascular Health and Physical Activity: Cardiovascular Health and Fitness Modules.

coach app

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