Q. I’m 53 and in my 20th year as a T4 paraplegic. A few of my friends with spinal cord injuries have been dealing with cardiovascular disease, which has ranged from coronary artery disease requiring angioplasty and stent placement, and in some cases bypass surgery, to peripheral artery disease in the legs that has required surgery to bypass narrowed arteries.

Is there a higher incidence of cardiovascular disease in people with SCI? Are there specific risk factors and/or symptoms? Are there tests to check for this that I should ask my doctor for? What are the treatment options? Are there ways to lesson chances of developing this?  
—Joni

A. Let’s start by defining cardiovascular disease and peripheral artery disease. Both refer to a systemic condition, sometimes called arteriosclerosis which, according to mayoclinic.com, involves “the buildup of fats, cholesterol, and other substances in and on your artery walls, which can restrict blood flow.” When this build-up, or plaque, occurs in arteries of the heart, it is called cardiovascular or coronary artery disease, and when it affects the legs, it is called peripheral artery disease. Since both diseases usually stem from the same underlying conditions, if you have one, you should ask your doctor to check for the other.

In the past, the leading cause of death in people with SCI was due to renal (kidney) complications. But thanks to advances in urological management, this is no longer the case. The flipside of this is now that life expectancy has increased, cardiovascular disease is the second-most common cause of death for people with SCI — behind respiratory complications — according to a study published in the June 2017 International Spinal Cord Society. The odds of a person with SCI developing cardiovascular disease are 2.72 times greater than in the general population, according to a study published in the August 2013 issue of Neurology that looked at a cross section of 60,000 individuals in the Canadian Health Care system.

Risk factors for CVD and PAD include a family history of heart disease, diabetes, lack of exercise, high blood pressure, and being overweight — especially fat around the mid section. Also, dyslipidemia — high levels of LDL (“bad”) cholesterol and a decrease in HDL (“good”) cholesterol — and a diet high in fats, and smoking or use of any form of tobacco. Symptoms for CVD are often silent and may be masked in people with higher level SCI who lack sensation to feel chest pain or shortness of breath, explains Kathleen Dunn, a recently retired clinical nurse specialist and rehab case manager. Dunn says unexplained chest pain and/or arm pain (not joint pain) especially if it is in the left arm, should be reported to a physician. This may mean going to the emergency room for an EKG and cardiac marker evaluation.

Since high blood pressure is a risk for CVD, checking blood pressure is important and should be part of an annual physical — or annual “wellness exam,” which is 100 percent covered under Medicare but must be asked for by name. Dunn says because dyslipidemia is also a risk factor and more common in people with SCI, starting at age 40 you should ask your physician for a cholesterol test — Medicare will pay 100 percent for this test every five years when ordered by a physician. She also suggests asking your physician about an annual EKG. Medicare covers 80 percent of this procedure.

If CVD is suspected, your physician may order additional tests, such as a stress test, to see how your heart responds to exercise. In people with SCI this is done using a medication called thallium, which raises the heart rate without exercise. Other tests include an echocardiogram — an ultrasound of the chest that shows detailed images of the heart; cardiac catheterization, in which a catheter is inserted into an artery in your leg or arm and threaded to the heart to measure blood flow; and/or a cardiac MRI or cardiac CT scan. None of these tests are painful. All are done while you are conscious or minimally sedated.

Similar to CVD, symptoms of PAD can also be masked by SCI, since the most common symptom is transient pain and/or cramping in the legs. Other PAD symptoms are frequent sores on the legs or feet that are slow to heal. But even then a PAD diagnosis can be missed, because these can also be caused by venous insufficiency (reduced return blood flow), which is common among people with SCI, explains Dunn. Testing for PAD is simple and painless. An ankle-brachial index test involves measuring systolic blood pressure on the arm and the ankle and calculating a ratio between the two numbers. The ratio will indicate the degree of disease — none, mild, moderate or severe. Follow-up is critical since disease progresses over time. Other options to test for PAD include Doppler ultrasound, magnetic resonance angiogram, or CT angiography — injecting contrast material into the bloodstream — and doing a CT scan.

The treatments for CVD and PAD are similar, beginning with lifestyle changes — stopping use of all tobacco products, proper diet, exercise and weight management, managing diabetes if you have it, and reducing stress. Treatment may include taking medications to manage cholesterol and/or high blood pressure, and blood thinners. When an arterial narrowing is suspected, one treatment is angioplasty — a catheter is threaded to the affected artery where a Foley balloon is inflated, flattening the plaque buildup and reopening the blocked area. In some cases, angioplasty may be followed immediately by insertion of a stent designed to keep the opening clear. Where extensive arterial disease is present, bypass graft surgery may be performed — a major operation involving grafting harvested or artificial arteries or veins to bypass the diseased area.

The best way to avoid or mitigate arterial disease is through lifestyle changes. Start with healthy eating. A healthy diet can lower LDL (bad cholesterol), raise good HDL (good cholesterol), reduce inflammation, lower blood pressure and even help strengthen arteries, says NEW MOBILITY nutrition guru Joanne Smith. According to Smith, who has an excellent YouTube video on the subject [see resources], a healthy cardio diet includes foods high in fiber, such as nuts and seeds; whole grains; plentiful fruits and vegetables; and healthy fats contained in cold water fish, such as salmon, herring and halibut; also, avoid processed foods.

It is also important to keep your body at its ideal weight. Although weight loss is more difficult for wheelchair users, a good place to start is to read Smith’s column — “SCI and Weight Loss” — in the December 2014 issue of NEW MOBILITY [see resources]. Last but not least, if you have arm movement, aerobic exercises or activities will help. In the July 2017 issue of Neurology, a review of 211 studies done between 1980 and 2016 found that moderate upper body aerobic exercise of 20-40 minutes for two to three times a week improves cardiovascular health in people with chronic SCI. The study found it also improves muscle strength, body composition — and speaking as “a survey of one” — it is a great motivator and mood elevator.

Resources
• Cardiovascular Disease & Nutrition Youtube video: www.youtube.com/watch?v=wunMybPK3I0&feature=youtu.be
• Cardiovascular disease and spinal cord injury:  www.ncbi.nlm.nih.gov/pmc/articles/PMC3776463/
• Causes of death after traumatic spinal cord injury — a 70 year British study:  www.ncbi.nlm.nih.gov/pubmed/28631749
• Craig Hospital Information about your heart: https://craighospital.org/resources/your-heart
• Atherosclerosis/arteriosclerosis: www.mayoclinic.org/diseases-conditions/arteriosclerosis-atherosclerosis/home/ovc-20167019
• Eat Well, Live Well: Weight Loss — More is Less!:  www.newmobility.com/2014/12/weight-loss/
• Effects of exercise on fitness and health of adults with spinal cord injury: www.ncbi.nlm.nih.gov/pubmed/28733344