Response to Letter to the Editor on “Traditional Cardiovascular Risk Factors Strongly Underestimate the 5-Year Occurrence of Cardiovascular Morbidity and Mortality in Spinal Cord Injured Individuals”

We thank the authors for their interest in our recent paper. In their letter, the authors expressed concern at the inclusion of certain endpoints (pulmonary embolism, chronic venous insufficiency, deep venous thrombosis, peripheral vascular disease, atrial fibrillation/flutter, or aortic aneurysms, valve diseases or dissection, and “other cardiovascular death”), because the Framingham Risk Score (FRS) prediction model was originally not set up to predict these endpoints. For this purpose, we repeated our analysis with 8 events (1 transient ischemic attack, 5 myocardial infarctions, 2 with angina) that fall within the FRS endpoints, as specifically defined by D'Agostino et al. Including these 8 events only, we found a borderline significant difference in clinical outcomes between individuals with a less than median FRS (eg, low risk) vs a greater than median FRS (high risk) with a risk ratio for clinical outcomes of 6.3 (95% confidence interval, 0.76-52.42; P=.088). Seven of the 8 cardiovascular disease events were recorded in the high FRS group. In addition, when the predictive value of the FRS alone was assessed by receiver operating characteristic curves, the area under the curve was 0.76 (95% confidence interval, 0.63-0.89). Overall, these additional subgroup analyses reinforce our original analyses, albeit caution must be noted because of the low number of events, which means the analyses are rather underpowered. This provided additional support for the observation of a remarkably high incidence of cardiovascular disease events in individuals with spinal cord injury ^, but also highlights the need to address these health issues in this group in future (pre)clinical work.