1 Risk Analysis for Cardiovascular Disease After Spinal Cord Injury. Please stand by for beginning of meeting. >>: Welcome everyone I would like to welcome everyone today to our web cast on risk analysis for cardiovascular disease after spinal cord injury. I am Suzanne Groah on RRTC on SCI. I am thrilled to have a good friend of mine but one of lead researchers on spinal cord injuries, Dr. Ann Spungen. She is a doctor at the Mt. Sinea Bronx in New York. She received her doctorial degree from Columbia in New York. She is the associate director of the Veterans administration RRTVA of the medical conditions of spinal cord injury. Located in Bronx New York. Has worked extensively with the cardiovascular disease. Please join me in welcoming her again for her talk titled risk analysis for cardiovascular disease after spinal cord injury. >>DR. SPUNGEN: Thank you. It is a pleasure to be here. Today I would like to cover 2 several topics. We are going to start with a risk factor description and using the assessment for insulin resistance, hypertension and review the traditional non-traditional emerging risk factors. In addition to these risk factors we are going to look at treatment goals and guidelines and then I will share some data with you that has been published by our group and several others across the country looking at our spinal cord injured patients. I am sure many of you are familiar with the American Heart Association Risk Factors for cardiovascular we have -- there are other contributors, stress and cholesterol of having a cardiovascular disease or an event. These include smoking, high cholesterol, high blood pressure. Diabetes mellitus. Smoking is an increasing risk factor. It increases heart disease 2 to 4 times. Person with disease who continue to smoke increase their risk by 2 times. It has negatively on other risk factors with cholesterol changes, blood pressure and 3 diabetes. Individuals who smoke cigars and pipes have an increased of death from cardiovascular disease. Secondhand smoke has been shown to increase the risk. Hi cholesterol, the greater the serum cholesterol the greater heart disease. Smoking the risk is amplified when one has high cholesterol. High blood pressure increases the work of the heart causing stiffening, increases the risk of stroke, kidney failure and heart failure. It also increases associated high cholesterol or diabetes. Physical activity or decreased activity increases risk. Individuals who have increased body fat increase the risk of heart disease as well as the risk of diabetes. In diabetes, three quarters of all these individuals die of some fort of heart or vessel disease. The American Heart Association risk factors or additional contributors, stress and alcohol and non-modifying are increasing in age -- greater than or equal to 65 years. Older age groups women who have 4 heart attacks are more likely to die than men. Men are at greater risk of heart attacks and occur earlier in life and post menopausal women -- increased but it still does not equal that of men. Ethnicity, there is a greater risk of children in parents with heart disease and a greater risk in Mexican, Native Americans than in Caucasians. The non-traditional emerging risk factors include insulin resistance, plasma homocystine,-- addition lack of protein A. Small density of the L particles. I am going to share data with you on the traditional risk factors for heart disease as well as these top 3 done in yellow, relative to your spinal cord injured patients in this presentation. When one conforms a risk factor assessment it is the lipid profile the oral glucose test and the blood pressure. One would screen for medical history, age, gender, obesity, physical activity level and stress or lifestyle. The ATP threes classifications was up dated at 2001. It is 5 recommended that individuals have LDL below 100, however the classification is -- 100 to 190 people very high. HDL, the cut off value used to be 35 and that has been increased to 40. These classification have become more stringent. Using the risk category classifications, if somebody has coronary heart disease or coronary heart disease risk, such as symptomatic heart disease o they are stratified into this 10 years risk of having an event of 10 years greater than 20 percent. Their LDL should be below 100. Individuals with two or more risk factors or a 10 year risk of less than 20 percent have an LDL of less than 100 milligrams per deciliter. The diagnostic criteria for disorders of carbohydrate -- one can check the fasting glucose, if they are below 100 that is been normal. The -- this has been made more stringent. It is recommended that a 2 hour glucose tolerance test be performed. Not all individuals who have the diagnosis of 6 diabetes have fasting increases plasma glucoses. For the risk factor analysis, point of course stratified by age, total cholesterol, smoker and none smoker. HDL, and systolic blood pressure. These this is an excellent website to find these information. With that review in mind looking at your spinal cord population and some of the studies a that have been publish established by hour group and other groups in the study. We studied individuals with spinal cord injury and their identical twin who was not injured and what we are looking at here on the -- on the Y axis is total body lean tissue bought -- we assume that each of these thoughts is the amount of lean total body lean tissues that we have lost from their twin, then we can see that with duration of injury, there is a substantively increased rate of lean tissue lost -- - medical center down in California, this is just single point in time data, we can see that individual able bodied individuals loose tissue across age at about one percent 7 per decade. However individual who's are paraplegia are losing at about 3 percent per decade. With this same said of subjects we looked at body mass index, many of you are aware that an I deal body mass index is 25 or less and that the well health organization will report at on obesity at 27, 30 or greater depending on the scores. One can see that if you are an able bodied individual, your body fat is around 20 percent with a body mass index of 25. However alarmingly in our SD I it trance LATSZ to more than 30 percent body mat which would qualify them. So in recurrence with SDI, they have higher percent fat, they lose tissue mass and they lose lean tissue mass at a greater rate over -- in the early 1990 we have studied 140 veterans. These were all males. In all these individuals none were diagnosed with diabetes when they were screen you had out for this study. We found that 22 percent of our SDI population had diabetes by the 2 hour glucose test where as -- 34 8 percent had impaired glucose tolerance -- versus 82 percent of the veteran able body study. In that came population, there is an increase with age, however our individuals with spinal cord injury are higher at the younger ages. So again with your Colleagues at the medical center in California looking at 2400 individuals, none veterans and they were slightly younger than your veteran population, we see that 13 percent of them had diabetes, 28 percent had impaired glucose tolerance and 59 percent were normal. Most of the individuals with -- 73 percent of them were found to have impaired glucose tolerance or diabetes. So there was a strong relationship with the degree of neurological deficit in the carbohydrate metabolism disorder. Additionally 53 percent of these with (not audible) and 37 percent of those were paraplegia. 26 percent of males had -- they have significantly higher peek at any similar glucose levels than the female 9 studies. 31 percent were found to be hyper insulin anemic, Older age at the time of injury and increased total body percent fat -- in insulin with male gender. In summary, there is an increased prevalence of impaired glucose tolerance and diabetes in your spine the cord, the worst the carbohydrate metabolism, it is independent related to percent fat, newer logical deficit, age at time of injury, and male gender. Greater than 30 percent with paraplegia. Oral glucose testing should be performed to diagnose early disease, mild diabetes. It is important to catch diabetes prior to the glucose increasing the diabetic level. Looking at 541 subjects we have reviewed their lipid profile and we found that newer logical deficit was strongly related to HDL which is shown on the left with the most -- having the lowest HDL cholesterol. In this relatively low population, 29 per vent had a serum HDL lower than 35. Now that cut off recommendations is 40. So this 10 percentage is certain to be much higher. The LDL, greater than 130 were almost 50 percent in each category. The complete tests having the greatest LDL. The total ratio was 55 to 44 percent depending on the newer logical deficit. So if we look at the ethnicity in your SDI population, people with African American decent had HDL values similar to that to the control population. They also had similar triglyceride patterns. Heritage and Latin population had lower HDL than the able bodied control. These are none veterans. There are lower HDL in your SDI population. Greater decrease in HDL is found within creasing neurological deficit and African Americans with SDI. The significance of plasma levels is the amino acid and its increased concentration are caused by -- renal and other diseases, various drugs and increasing age. Increased levels are associated within creased heart disease. This is our range of population again. We looked hat 11 the home owe sis teen levels and if you will notice that if you are in the range of 15 to 19 the mortality ratio is 2.8 and if you are greater than 20, it is 4.5. We find the higher percentage 33 and 11 percent having a homocystine levels in a range that put them at risk. Reactive protein is a general marker for inflammation -- a cute inflammation and it is also associated with increased heart disease. A relatively small group sampled the group from Palo Alto, studied protein levels but the finding was alarming. There was a high percentage with a moderate, high and high degree. Those with a fasting insulin resistance, again putting this population at risk for heart disease. In summary, 44 percent of the SDI patients studied had a homocystine level increased with the mortality ratio. 62 percent had moderate CRP levels. Looking at 100 individuals with -- 119 with paraplegia. We did a risk analysis with them. Relatively young, 26 years old. 12 Duration of injury 16. BMIs in the mid 25 range for both groups. Your par as were slightly older than tetras. Looking at the major risk factors, 31 percent were smokers. 34 percent in the par as were smokers. Only -- expect to find and 32 percent of your par an as were hyper ten SIF. 60 percent of your par as had HDL below 40. 33 percent had family history of coronary heart disease and more than half were over 45 years old in both groups. So using the 10 year risk assessment we found that 5 percent of tetras and 12 percent of paras had diagnosed coronary heart disease. 4 percent and 6 per certain had diabetes. 17 percent in both groups were additionally gowned to be have diabetes. I would like to make a note without having done the oral glucose testing they would have gone undiagnosed. 2 and 5 percent had the 10 year risk of greater than 20 percent. A large major, 66 and 79 percent had 2 or more risk factors. And 10 year risk of 13 -- 57 percent ask we see the hypertension coming into play because they are heavily counted with identifying the 10 year risk and we see that our par as have significantly greater risk factors at the 10 to 20 percent than the tetras. Likely do to the hypertension. Shown here is the lipid profile, triglycerides and HDL. What we have in yellow are the mean values or -- population. SMOEN in blue, mean values for all veterans, for those values. We see that our SDI veterans are a little lower on triglycerides and about the same on total, and LDL. It is HDL where they have a much higher average and that 38 is representing our SDI patients. HDL is less than 40. We have included 63 percent of group studied. If you stratify to less than 30 we have an alarmingly high percentage of individuals having HDL below the recommended level. The medium is 38. If we look at how many patients were categorized, we see that this is the percent 14 who need he had treatment, in terms of making the LDL. Finding these patients and getting them -- 41 percent of the SDI population qualified. So in summary, the highest risk LDL goal of less than 100 milligrams was in 727 subjects. 9 percent had cardiovascular disease diagnosis or vascular disease. Many of these may have silent diseases and maybe missed due to a symptomatic. 17 percent had diabetes without oral glucose tolerance test and how many of them with the impaired glucose are really at risk. This probably would have been higher if we included known diabetes. 58 of the 222 subjects, 50 percent had a 10 year risk of 10 to 20 percent and 70 percent had 2 or more risk factors. Overall 41 percent qualified for intervention. Good friend of ours and colleague, he recently published his out come of risk factor analysis and spinal cord injury and in 42 subjects who were T 6 to L1 whether an age of 41 years which is 15 years younger 15 than our group. He looked hat the percent of subject -- he found that 63 percent of the subject qualified for intervention. A third had hypertension. Remember these are all individuals with paraplegia. And 44 percent had the medium BOL I can syndrome. A high per taking of young are at risk. HDL, person with spinal cord injury are frequently depressed and require higher scrutiny, they have depressed values requiring more intense intervention. Associated symptoms of cardiovascular disease may result in-- of coronary heart disease risk resulting in reduced depreciation of risk. Conventional risk factors should be treated with SDI according to standard of care. I want to give thanks to the department of veterans affairs Rehabilitation Research and Training Center in Washington, James J. Peters in Bronx VA to United spinal association, Kessler institute of rehabilitation in New Jersey. Staff whom of which we could not complete the work we have 16 done. Thank you very much. >>: Do you know if any of this has made it into the clinical realm. We actually have a pretty good wealth of litter and the next step that needs to be done or in development is developing the screening and survey lens guide lens. >>: Earlier in the 90 we began doing oral glucose tolerance testing and lipid screening and now that the part of their annual physical. It took 10 years to make that part of the annual physical to convince the individuals there that the data was supporting that it should be a screening annually. The testing is the normal. They come back once every 5 years: If they are impaired we do it annually. As far as the actual treatment, looking at stratifying the patient for 10 year risk assessment and then treating them with the LDL goal, in practice, it is practiced individually by the physicians in the know but I don't see it as policy. >>: Is the surveillance being 17 done at the one year follow up or specific age ? >>: Well the veterans are -- I don't know how it is handled but in the veterans population they come in every year for their annual check up and during that time once if they become injured they know right into that annual advice it and it is at that time we screen their lipid and their oral glucose tolerance test. We have a metabolic and endocrine clinic now at the Bronx VA where they are seen and treated for lipid and diabetes. >>: Routine screen no. We have studied it but in terms of a clinical at this time has not been done. >>: Intervention, I had interested in those figures about 41 percent and I guess the others close to 70 percent are candidate for intervention. What strategies do you to us to raise HDL? >>: Well Mark NASH and Bill, they use new span to raise the HDL and they have not reported the data on it. I don't know. I believe it has a significant effect 18 but into that is published. I don't know of any efforts to raise it at this point. In all research, one tries to describe the problem and then there is also a lag to get the clinical interventions in place. >>: Does the data suggest that that works -- >>DR. SPUNGEN: Niaspan has been shown to increase HDL. >>: Who kind of -- do you see? >>: I don't know the answer to that. I think 5 to 10 million grams but I would have to check. >>: Have you looked at exercise and activity as it relates to these variables. >>: Isn't early 1990s we used the Regis system and we studied 10 individuals with tetraplegia an and we followed their HDL 3 times a week and we -- not been pub accomplished as a paper but we did find a significant increase of an average of 28 to something in the mid 40's. So we did get an increase. As far as your work with paraplegia, there are several studies out there being done to see if it can increase the 19 HDL. It is shown by RON out of Pittsburgh, that physically individuals have a higher HDL than in active paraplegics. >>: I have one more question because I also think the information that you presented is critical, lean body mass and the change in body composition, I am not sure -- in the twin study that you followed the patients is there any indication, obviously loss of body mass early is going to be the highest, is there a point at which that plateaus. >>: Most of the bone the lost during the first year of injury, lean tissue and fat is gained through out the rest of their live. That twin study showed us that these individuals continue the lose lean tissue, they continue to lose bone tissue and increase in fat tissue. The cross section A data, also shown decrease in lean tissue. If we look hat the legs of individual was tetra plegia and paraplegia they lack lean tissue with age. We look at the lean tissue with control in our age. Both of them have the same rate of loss. The par as 20 and the tetras and the controls. The pair as and tetras are significantly reduced. There is a lot of variance for what is left in the tissue for the individuals in what they are losing. So the total body percent lean tissue, a large amount is in the trunk and upper body and that being because the legs are already lost. -- Bill and I, him being an endocrinologist, being this is related to hormonal changes. We have shown that individuals with spinal cord injury have reduction in growth hormone and testosterone, and these are the or hormones that help us keep lean tissue -- >>: I was interested in mechanism of the elevated LDL and HDL and maybe it has to do with the changes in hormones. >>: I'm not sure they would know the mechanism in the general population. We know that there are a lot of associations when you lose lean tissue you cannot take up as much glucose so you have a greater risk of glucose I am pair meant. The causes and 21 mechanisms I cannot answer for you. >>: It is interesting to note that it is rerated to level of injury >>: Yes. >>: So it make you wonder what is going on that would cause a greater or lesser -- >>: There is lots that we can speck late. Right now the lost of testosterone and growth hormone does not appear to be related -- the longer they are injured the greater the loss. However, the one thing we do is that tetras lose more lean tissue than paras. So this neurological deficit, the complete tetras have the worse insulin resistance, maybe more likely related to loss of lean tissue and relatively increases in fat tissue. >>: One more question do you know of any effective intervention for treating elevated CRP >>: I don't. >>: Either group >>: No. You know, C reactive protein is largely related to inflammation and maybe the treatment would be -- our 22 individuals with spinal cord injury have so many infections, UTI, so it maybe that their degree of sepsis they have has increased the CRP. We don't know the answer. I am just speculating. Treating infections early on and keeping them under control may help reduce the CRP levels. >>: There is an inflammatory component with patients with CRP >>: That's correct. Thank you. >>: Now, as you know, we are web casting this presentation and I'd like open up for questions as well from our ILRU for questions. >>: We have several questions. If first one is would you recommend that is person with is spinal cord injury see an endocrinologist on a regular basis >>: If they know and is aware of those problem was spinal cord injury. Absolutely I would. However, there is no reason why the attending and staff physicians who treat spinal cord patients couldn't treat them for these disorders. Its common 23 knowledge and most of them trained to assess for risk. They can follow hoe the guidelines and treat them a properly. >>: Another question is -- this is all great information, information that person need to know. Do you have any check list or other tools that the person with SDI an request these that might not otherwise be offered to them. >>DR. SPUNGEN: Well I hope I don't offend anyone but they are for the general population and they are well established and have been developed by an expert panel and are reviewed every 10 years and up dated a properly but some of the worlds best physicians for risk identification, at the very least or SDI patients should be treated by following those guidelines. There is nothing we need to do at this point or that we know to do that is any more special than what the general population gets for treatment. So at the very least, following those guidelines that are there and exist for the general population, they should also be given to your spinal cord 24 injured patients. I think what happens is that many treating -- are caught up in treating the problems unique to spinal cord injury that the other problems that we all get as we age, specifically risk for coronary heart disease increases, are being overlooked. >>: Where would consumer finders -- >>DR. SPUNGEN: Do you have access to these slides. The website was on one of slides. It is an-- you could Google ATP 3 and they would come up. >>: Other question is what is considered excessive alcohol use >>DR. SPUNGEN: More than one drink per day in women and more than two in men. >>: Who about intervention what types of things can you do for prevention >>DR. SPUNGEN: Why don't we start with the oral glucose tolerance test, if an individual has a normal fasting plasmas glucose and we perform an glucose tolerance test and we find they have impaired glucose 25 and hyper insulin anemia but they do not have a diabetic diagnoses, that person is a key individual to intervene to prevent the further development of diabetes. If left untreated you are likely to become a diabetic. When that occurs, no one knows. It depends on who you are and -- if you can intervene and that's the time to intervene with diet and exercise. If you can get the weight off and get the mass, you are likely to reverse that cascade of going on and progressing to a diabetic. In terms of getting the HDL raised, my activity would be helpful. It is associated with increases in HDL. Niaspan will increase HDL. An individual with complete tetraplegia is going to have difficult being active enough. The interventions maybe the function electronical stimulation and those that provide assistance for those individuals. >>: When -- you are saying niaspan >>DR. SPUNGEN: Yes, >>: Is that a prescriptions? 26 >>DR. SPUNGEN: Yes. In terms of LDL, there are many drugs available. That is not the realm for me to talk. They are at your hospital centers >>SUZANNE GROAH: I think another message, the slide on BMI, not necessarily to rely on health organization guidelines. It is a little bit of a tough line if an individual with spinal cord injury over weight is defined of a BMIs of 25 or greater, but for an individual with spinal cord injury that number is probably lower because we do know about the increase in fat mass and the decrease in lean body tissue. So I think before we get to a point of having some changes in lipids or changes in glucose, people can be very, very, careful and prudent ask try to eat the healthiest diet possible, that should buy some time. I also think you don't want to go on the extreme end of becomes BMI too low. Exercise as much as possible >>DR. SPUNGEN: Exercise is certainly one of the best ways to go for this population. It will do a 27 lot of good. It is a tough call because of the shoulder and joint problems that result. Of course that's the labor intensive, only mostly available in a research setting. So whatever we can do to improve the ability of individuals with disabilities to exercise is an important take home message here for them. >>: Other question, can you explain between the relationship of diabetes and cardiovascular disease. >>DR. SPUNGEN: That's a tough question. If you have diabetes you develop something called micro vascular disease and macro vascular disease. Usually one develops macro vascular disease early on and that results in visual problems, poor circulation to the feet and that in turn result notice pressure you will certificates. When you have Macro vascular disease you are likely to have atherosclerosis in the heart. That is all increased and augmented with diabetes. >>: Who about vitamin deficiency. Is there any type you 28 can take that will help with hormones or -- >>DR. SPUNGEN: The number one vitamin deficiency we see is vitamin D . That mostly effects bone metabolism. If an individual isn't getting outdoors or drinking milk products. Patients have been told to avoid high calcium foods because of kidney stones but that's really not the problem. If you don't have enough vitamin D because you have reduced your milk and cheese and dietary in take, then you are at risk of having greater loss of bone density. That effect on the heart I am not aware of. Vitamin deficiency related to heart disease, I don't know of any. Especially the SDI population. >>: That's all on this end. >>DR. SPUNGEN: Thank you. >>: Thank you. >>: One more questions came in. They are e-mailed to us. As far as a prediabetic, do you ever recommend increasing your protein in take or limiting your eating of breads and pasta. I am hearing of quick weight loss 29 with that. >>DR. SPUNGEN: I am a firm believer of reducing simple carbohydrates in the diet. We don't want to increase the risk of heart disease with a high fat diet. If one can increase protein and decrease simple carbohydrates that will help them with glucose metabolism. >>: That's it. Thank you. >>: I think the other message that I think I am taking away from this is what can I do has a consumer and I think the message is clear. Follow the guidelines that have been established for the general population. The key might be is to take the initiative and approach your physician probably earlier than you might anticipate with respect to your age. Then we have talked about accelerated age. The physicians have guidelines they can use to implement. The consumer tries to be physically active. Don't injury in your shoulder and keep that in mind. Try to keep that body mass index a little bit lower than the 30 guidelines for the general population, but take the initiative from your health care provider. Looking at these key risk factors earlier than the health care provider might be looking at it. >>: If I can quote any Colleague, he likes to say if you look for it then you will find it and then you can treat it. >>: With that I would like that thank Dr. Ann Spungen. This was a great talk and we are going to continue with hour work together but you have done great work in the area. I would like to thank your colleague at ILRU. The webcast will be archived so it can be viewed on manned a text manuscript will be also be available at the IRLU. Captioner Leah Halm. And Rick Dickehuth at Baylor College of Medicine and the rest of your team at ILRU. And NRH who worked closely. Again thank you everyone.