Spinal cord injury is one of the most costly chronic conditions to the VHA, with an estimated annual cost of $26,735 per person. Diminished autonomic cardiovascular control following SCI can result in abnormal blood pressure, blood flow and heart rate, the degree of which may or may not be related to the level and completeness of SCI (3, 4). However the prevalence of blood pressure abnormalities in this population is not well described, and the magnitude of increased healthcare use and cost associated with blood pressure abnormalities has yet to be determined. In persons with tetraplegia arterial blood pressure is usually low (11), however the prevalence of hypotension (i.e., d 110/70 mmHg) was reported to be 16% among a large cohort of veterans with SCI (13). The relatively low prevalence of hypotension documented may reflect postural positioning during the blood pressure assessments because several smaller studies report an increased prevalence of orthostatic hypotension among individuals with tetraplegia (2, 5, 11). Individuals with tetraplegia also have increased prevalence of extreme hypertension, commonly diagnosed as autonomic dysreflexia (AD) (1, 6, 9). Autonomic dysreflexia is generally triggered by a noxious or non-noxious stimulus below the level of SCI and often presents with symptoms including pounding headache, pallor, pilomotor erection, increased spasticity and flushing of the head and neck (1, 6, 9);although 'silent'AD occurs and can have fatal consequences (10, 12). A recent publication suggests an increased age-adjusted prevalence of hypertension in persons with paraplegia (4);another study, based on self-reported data, suggests the prevalence of hypertension is doubled among the SCI compared with the general population (49% versus 26%) (14). The clinical consequence of under diagnosed blood pressure abnormalities in veterans with SCI would result in inadequate treatment of the condition which in turn may increase the incidence of end-organ disease and increase the financial burden on the healthcare system for long-term care of veterans with SCI. Further, the validity and reliability of ICD-9-CM diagnosis codes associated with blood pressure abnormalities contained within VA administrative datasets is currently unknown. Research initiatives aimed at gaining a better understanding of the prevalence of these disorders are warranted. The purpose of this pilot investigation is to determine the prevalence of blood pressure abnormalities observed during routine physical examinations and clinical procedures in veterans with chronic spinal cord injury (SCI) and to compare the observed prevalence of blood pressure abnormalities to the documented prevalence recorded in the VA administrative databases between the FY 2004-2008.
Relevance of the Proposed Work to the VA Patient Care Mission It is the mission of the Department of Veterans Affairs to provide optimal clinical care for all patients. Compared with able-bodied veterans, persons with SCI require additional health care, which may be related to the degree of neurologic impairment or to chronic immobilization secondary to skeletal muscle paralysis. It is important to address the secondary complications of neurologic impairment and paralysis in order to improve the longevity and quality of life of persons with SCI. Better identification of patients with specific types of blood pressure (BP) abnormalities will help target patients at risk for these conditions which would in turn improve patient care. Individuals with SCI confront the daily challenge of managing their unstable BP, which frequently manifests in persistent hypotension and/or hypertension, as well as episodic uncontrolled hypotension and/or severe hypertension. However, the recognition and management of these BP abnormalities following SCI represents a challenging clinical problem. Hypertension alone or in the presence of autonomic dysreflexia (AD) may be under-diagnosed and consequently mismanaged in persons with chronic SCI. Further, because elevated BP is common to EH and AD, distinction between these two entities is challenging. The clinical diagnosis of chronic hypotension and OH may also evade clinical assessment due to random presentation. Consequently, clinical BP readings often prove insufficient, rendering traditional outpatient evaluation and management suboptimal. The VA has the largest single network of SCI&D care in the nation which offers a wide range of care and serves to more than 25,000 veterans with SCI&D (www.sci-queri.research.med.va.gov). Significant gains in our understanding of the prevalence of BP abnormalities in persons with SCI can be made within the VA administration and these gains will lead to improved care, health and longevity of individuals living with chronic SCI throughout the world. As a by-product of this research study, a highly significant system-wide cost-savings would be realized due to reduced hospitalizations which stem from understanding the prevalence of BP abnormalities in persons with SCI, enabling tailored treatment options to meet individual needs and physiologies.
|Wecht, Jill M; Weir, Joseph P; Galea, Marinella et al. (2015) Prevalence of abnormal systemic hemodynamics in veterans with and without spinal cord injury. Arch Phys Med Rehabil 96:1071-9|
|Wecht, Jill M; Cirnigliaro, Christopher M; Azarelo, Frank et al. (2015) Orthostatic responses to anticholinesterase inhibition in spinal cord injury. Clin Auton Res 25:179-87|