Prevalence of Abnormal Systemic Hemodynamics in Veterans with and without Spinal Cord Injury

Advances in the clinical management of patients with acute and chronic spinal cord injury (SCI) have contributed to extended life expectancies; however longevity in those with SCI remains below that of the general population.(1) Reduced longevity in the SCI population has been attributed to increased incidence of age-associated chronic illnesses,(2) premature cardiovascular aging,(3) and increased prevalence of heart disease, stroke (4) and diabetes mellitus, (5) compared to the general population. In fact, cardiovascular disease (CVD) is now a leading cause of morbidity and mortality in the SCI population, which may be amplified due to increased risk factors such as inactivity, chronic inflammation, and impairment in autonomic cardiovascular control.(6) The American Spinal Injury Association (ASIA) impairment scale (AIS) is used to document remaining motor and sensory function following SCI; (7, 8) however, the degree of autonomic nervous system impairment is not considered within this classification schema.(9, 10) That said, impaired autonomic control of the cardiovascular system after SCI results in measurable changes in heart rate (HR) and blood pressure (BP) that loosely reflect the level and completeness of SCI documented using the AIS classification, (11, 12) but may also reflect orthostatic positioning.(6, 12, 13) The impact of these changes in HR and BP on cardiovascular health and longevity is not fully appreciated in the SCI population; however, prior to identifying the consequences of these cardiovascular abnormalities, prevalence rates of HR and BP values which fall outside the expected normal range should be documented. The International Standards to Document Autonomic Function (post-SCI) initially established guidelines for the assessment of HR and BP abnormalities in 2009, (10) which was updated in 2012, but the thresholds remained consistent. (14) Specifically, bradycardia is defined as a HR ≤ 60 beats/minute (bpm) and tachycardia as a HR ≥ 100 bpm. (14) Hypotension is defined as a systolic BP (SBP) ≤ 90 mmHg and a diastolic BP (DBP) ≤ 60 mmHg; hypertension is SBP ≥ 140 and/or DBP ≥ 90 mmHg. (14) While these definitions comply with standards established in the non-SCI population, due to decentralized cardiovascular control, they may not be appropriate for use in the SCI population. In addition, relatively recent evidence has emerged which associates adverse outcomes in the general population using other HR (15, 16) and BP (17-21) thresholds. Beyond the clinical consequences of alterations in HR and BP, persons with SCI may experience loss of independence and life quality related to the inability to adequately maintain cardiovascular homeostasis; however, until we gain a better understanding of the prevalence of these abnormalities, the development and testing of effective treatment strategies will not be a priority. Therefore, the goal of this investigation was to assess HR and BP in veterans with (SCI) and without SCI (non SCI). Similar to a recent report, (6) we hypothesized that level of SCI (i.e., the higher the lesion level the greater the prevalence of abnormal HR and BP recordings) and orthostatic positioning (i.e., increased prevalence of abnormal HR and BP recordings in the seated versus the supine position) would influence the prevalence of HR and BP abnormalities. In addition, we hypothesized that the prevalence of comorbid cardiovascular medical conditions, current smoking status, age and use of prescription anti-hypertensive (anti-HTN) medications would influence the prevalence of HR and BP abnormalities in veterans with and without SCI

COVID-19 in Spinal Cord Injury Patients at a Veterans Administration Hospital: A Case Series

OBJECTIVE: To describe the clinical features and disease course of COVID-19 in veterans with spinal cord injury (SCI). DESIGN: Case series of consecutive veterans with SCI treated at a single center. SETTING: SCI Unit at an urban Veterans Administration hospital at the epicenter of the COVID-19 pandemic in the US. PARTICIPANTS: Seven SCI veterans with confirmed COVID-19 infection by PCR; all veterans were male, mean age was 60.6. Five had cervical level of injury, and five had complete injury (AIS A). Six veterans had a BMI \u3e 22; three had chronic obstructive pulmonary disease; three had chronic kidney disease. INTERVENTIONS: None. OUTCOME MEASURES: Presence of co-morbidities, diagnostic values, and clinical findings. RESULTS: Each case presented differently; the most common presenting sign was fever. In the three individuals with critical and fatal infection, pre-existing comorbidities were more common and inflammatory markers were markedly elevated. CONCLUSION: Level and completeness of SCI did not appear to correlate with COVID-19 severity, as mild and asymptomatic illness was noted in persons with high grade SCI. As has been shown to be the case in the general population, pre-existing comorbidities are the most reliable predictors of severe SARS-CoV-2 infection currently available for persons with chronic SCI. Contrary to concerns that SCI may mask the cardinal signs of COVID-19, such as fever and cough, by way of compromised thermoregulation and thoracoabdominal musculature, such signs were common in our series. To facilitate early detection, prompt treatment, and minimized viral spread, the implementation of preventive strategies by SCI units is recommended

Health impacts reported in the Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES)

In people with spinal cord injury (SCI), infections are a leading cause of death, and there is a high prevalence of diabetes mellitus, obesity, and hypertension, which are all comorbidities associated with worse outcomes after COVID-19 infection. To characterize self-reported health impacts of COVID-19 on people with SCI related to exposure to virus, diagnosis, symptoms, complications of infection, and vaccination. The Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES) study was administered to ask people with SCI about their health and other experiences during the COVID-19 pandemic. 223 community-living people with SCI (male = 71%; age = 52±15 years [mean±SD]; paraplegia = 55%) completed the SCI-CPES. Comorbidities first identified in the general population as associated with poor outcomes after COVID-19 infection were commonly reported in this SCI sample: hypertension (30%) and diabetes (13%). 23.5% of respondents reported a known infection exposure from someone who visited (13.5%) or lived in their home (10%). During the study, which included a timeframe when testing was either unavailable or scarce, 61% of respondents were tested for COVID-19; 14% tested or were presumed positive. Fever, fatigue, and chills were the most common symptoms reported. Of the 152 respondents surveyed after COVID-19 vaccines became available, 82% reported being vaccinated. Race and age were significantly associated with positive vaccination status: most (78%) individuals who were vaccinated identified as Non-Hispanic White and were older than those who reported being unvaccinated (57±14 vs. 43±13 years, mean±SD). Self-reported COVID-19 symptoms were relatively uncommon and not severe in this sample of people with SCI. Potential confounders and limitations include responder, recruitment and self-reporting biases and changing pandemic conditions. Future studies on this topic should query social distancing and other behavioral strategies. Large retrospective chart review studies may provide additional data on incidence and prevalence of COVID-19 infections, symptoms, and severities in the SCI population.</p