Response to La Fountaine et al.

Abstract

La Fountaine et al. [1] recently compared the lipid profiles of 401 persons with chronic spinal cord injury (SCI) with those of 197 able-bodied controls. In so doing, they found that adverse serum triglyceride (TG) concentrations in people with SCI are lower than in those without, and reiterated previous insights into links between sympathetic nervous system input and circulating lipid levels.While this article is well reasoned-and each of its authors has substantively contributed to the physiatric literature-the reader is left questioning its clinical relevance. In concluding that clinicians should "consider instituting appropriate dietary, exercise, and/or pharmacological interventions" in patients with elevated TG concentrations, the authors obscure the fact that none of these has been shown to reduce atherosclerotic burden, risk of major adverse coronary events, or cardiac or overall mortality in people with SCI. There are simply no data upon which to base these recommendations.Further, while the authors rightly point to recent guidelines reaffirming that low high-density lipoprotein levels are a major risk factor for cardiovascular disease (CVD) and that TG levels ≥200 may identify individuals at increased risk (Grade B recommendation) [2], it is not clear what to do with this information. A review of the use of fibrates for primary prevention of CVD revealed a modest benefit over placebo for combined endpoints, but none for overall or non-CVD mortality [3]. A separate review of the efficacy of niacin with or without the addition of a statin demon-strated no reduction in overall mortality, cardiovascular mortality, or fatal or non-fatal myocardial infarctions when compared with placebo [4].While La Fountaine et al.'s article is cleanly written and argued, it underscores the need for a certain aggression in tackling cardio-metabolic disease in SCI. Rather than descriptive analyses of lipid profiles or discussion of how cardiovascular risk factors cluster in people with injuries [5], we need trials of interventions with hard and tangible outcomes. As CVD emerges as the leading cause of mortality among individuals with SCI, what can and ought we do to improve their health and longevity?Compliance with ethical standards

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