The Prevalence of Blood Pressure Abnormalities among Veterans with SCI

描述（由申请人提供）： 脊髓损伤是VHA最昂贵的慢性疾病之一，估计每人每年的费用为26，735美元。SCI后自主心血管控制能力下降可导致血压、血流量和心率异常，其程度可能与SCI的水平和完整性有关，也可能无关（3，4）。然而，该人群中血压异常的患病率尚未得到很好的描述，与血压异常相关的医疗保健使用和成本增加的幅度尚未确定。在四肢瘫痪的人中，动脉血压通常较低（11），然而低血压的患病率（即，d 110/70 mmHg）的比例为16%（13）。记录的低血压患病率相对较低可能反映了血压评估期间的体位，因为几项较小的研究报告了四肢瘫痪患者中直立性低血压的患病率增加（2，5，11）。四肢瘫痪的个体也有极高血压的患病率增加，通常诊断为自主神经反射异常（AD）（1，6，9）。自主神经反射障碍通常由SCI水平以下的有害或无害刺激触发，通常表现出剧烈头痛、苍白、立毛勃起、痉挛增加和头部和颈部潮红等症状（1、6、9）;尽管“无声”AD发生并可能产生致命后果（10、12）。最近的一份出版物表明，截瘫患者的年龄调整后高血压患病率增加（4）;另一项基于自我报告数据的研究表明，SCI患者的高血压患病率是普通人群的两倍（49%对26%）（14）。未被诊断的SCI退伍军人血压异常的临床后果将导致对病情的治疗不足，这反过来可能会增加终末器官疾病的发生率，并增加SCI退伍军人长期护理医疗保健系统的经济负担。此外，与VA管理数据集中包含的血压异常相关的ICD-9-CM诊断代码的有效性和可靠性目前尚不清楚。有必要开展旨在更好地了解这些疾病患病率的研究活动。本试点调查的目的是确定在慢性脊髓损伤（SCI）退伍军人的常规体检和临床程序中观察到的血压异常的患病率，并将观察到的血压异常患病率与VA管理数据库中记录的2004-2008财年的患病率进行比较。 公共卫生相关性： 拟议工作与VA患者护理使命的相关性退伍军人事务部的使命是为所有患者提供最佳临床护理。与身体健全的退伍军人相比，SCI患者需要额外的医疗保健，这可能与神经功能缺损的程度或继发于骨骼肌麻痹的慢性固定有关。重要的是要解决神经功能障碍和瘫痪的继发性并发症，以提高SCI患者的寿命和生活质量。更好地识别具有特定类型血压（BP）异常的患者将有助于针对这些疾病的风险患者，这反过来又会改善患者护理。SCI患者每天都面临着管理其不稳定血压的挑战，这通常表现为持续性低血压和/或高血压，以及间歇性不受控制的低血压和/或严重高血压。然而，识别和管理这些血压异常后SCI代表了一个具有挑战性的临床问题。在慢性SCI患者中，单独的高血压或伴有自主神经反射异常（AD）的高血压可能诊断不足，因此管理不当。此外，由于血压升高是常见的EH和AD，这两个实体之间的区别是具有挑战性的。慢性低血压和OH的临床诊断也可能由于随机表现而逃避临床评估。因此，临床血压读数往往证明是不够的，使传统的门诊评估和管理次优。VA拥有全国最大的SCI&D护理网络，提供广泛的护理，为25，000多名SCI&D退伍军人提供服务（www.sci-queri.research.med.va.gov）。我们对SCI患者血压异常患病率的理解可以在VA管理中取得重大进展，这些进展将改善全世界慢性SCI患者的护理、健康和长寿。作为这项研究的副产品，由于了解SCI患者BP异常的患病率，减少了住院治疗，从而实现了非常显著的全系统成本节约，从而实现了量身定制的治疗方案，以满足个人需求和生理学。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: 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.