The authors wish to thank Drs. Stillman and Williams for their Letter to the Editor and for the opportunity to further discuss our recent publication entitled '”Establishing a threshold to predict risk of cardiovascular disease from the serum triglyceride and high-density lipoprotein concentrations in persons with spinal cord injury” (SCI) [1], as well as some aspects of our prior work. Echoing many of the concerns in their Letter to the Editor, we too have struggled with the dearth of empirical evidence on how best to approach cardiovascular disease (CVD) risk-factor stratification, the lack of appropriate guidelines on threshold concentrations for specific lipids at which to intervene, and the scarcity of information on what agent(s) and/or modalities (e.g., diet, exercise) should be used and when, if indicated, in persons with SCI. Our article in this issue of the journal serves to highlight the lack of SCI-specific guidelines on reducing risk factors for CVD, and it also functions to emphasize the absence of evidence demonstrating the efficacy of CVD risk factor reduction to reduce hard CVD end points (e.g., stroke, myocardial infarction, sudden death due to presumed or proven CVD) in longitudinal cohort studies in persons with SCI. The authors appreciate the multiple challenges to develop research proposals on topics that are of interest to funding agencies, the monumental task to design and execute large-scale clinical trials in persons with SCI, and the perseverance required to generate level 1 evidence that has generalizability across a heterogeneous SCI population, with the outcome aimed to influence how medicine is practiced. Admittedly, due to the multi-factorial etiology for CVD and the possibility of distinct pathophysiological attributes unique to persons with SCI, controversy may exist on the appropriateness of applying guidelines for able-bodied individuals to those with SCI. However, in the absence of clinical trials that address hard CVD end points in the SCI population, clinicians are left to apply accepted practices or research findings that are derived from the general population to support patient care decisions.

The current practice guidelines in the general population favor lowering the low-density lipoprotein cholesterol (LDL-C) concentration as the primary target for CVD risk, and, to a lesser degree, emphasis is placed on increasing the high-density lipoprotein cholesterol (HDL-C) or lowering the triglyceride (TG) concentration. The authors concur with the two main points advanced by Drs. Stillman and Williams concerning our article [1] in this issue of the journal: (1) the clinical benefit of lowering the serum TG concentration to reduce incident CVD events or overall mortality has not been established in persons with SCI, and (2) there is a need for clinical trials in the SCI population to address the efficacy of interventions to reduce hard CVD end points.

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