Commentary on Comparison of Coronary Artery Calcification Scores, National Cholesterol Education Program Guidelines for Coronary Heart Disease Risk Assessment, Treatment Paradigms in Individuals with Chronic Traumatic Spinal Injury
Jesse A Lieberman*
Department of Physical Medicine and Rehabilitation, Carolinas HealthCare System, USA
- *Corresponding Author:
- Jesse A Lieberman, MD, MSPH
Department of Physical Medicine and Rehabilitation
Carolinas Health Care
Received date: May 18, 2017; Accepted date: June 06, 2017; Published date: June 13, 2017
Citation: Lieberman JA (2017) Comparison of Coronary Artery Calcification Scores,
National Cholesterol Education Program Guidelines for Coronary Heart Disease
Risk Assessment, Treatment Paradigms in Individuals with Chronic Traumatic
Spinal Injury. Int J Neurorehabilitation 4:273. doi:10.4172/2376-0281.1000273
Copyright: © 2017 Lieberman JA. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
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This commentary considers the implications of the findings related to the effect of a study related to coronary heart disease (CHD) risk assessment in individuals with a chronic spinal cord injury (SCI). The findings from the study suggest that there is poor agreement in CHD risk assessment between the previously used guidelines, the National Cholesterol Education Program (NCEP) Guidelines, and coronary artery calcium scores (CACS). Since this publication, a new atherosclerotic cardiovascular disease (ASCVD) risk estimator has been developed. This has not been used in any study with SCI participants. The study also showed that 18 (47.4%) of the participants had some element of CAC, indicating the presence of CHD. Many previous articles have discussed CHD risk factors and mortality in the SCI population. Despite this, there have been very few interventions to decrease the CHD risk in the chronic SCI population.
This commentary considers the implications of the findings related
to the effect of a study related to coronary heart disease (CHD) risk
assessment in individuals with a chronic spinal cord injury (SCI)
described by Lieberman et al. . This was a cross-sectional study
comparing the use of coronary artery calcium scores (CACS) and the
National Cholesterol Education Program (NCEP) Guidelines for CHD
risk assessment. The authors reported only an 18% Percent Agreement
between the two risk assessment tools with a Kappa of -0.03. They also
reported that 18 (47.4%) of their participants had a CACS>0, indicating
that they had some level of CHD.
This article has been referenced 17 times, two of which were
improperly referenced. Of the nine publications in English with SCI
participants, eight were review articles. There were not any articles
describing the new CHD risk estimator tool described below and there
were not any articles further exploring CACS as a risk assessment tool
in the SCI population. In addition to this, there were not any articles
describing an intervention aimed to decrease the elevated CHD risk in
the SCI population that referenced the Lieberman et al.  article.
Since the time of the publication by Lieberman et al. , the NCEP
guidelines have been replaced. A new atherosclerotic cardiovascular
disease (ASCVD) risk assessment tool has been adopted by the American
College of Cardiology (ACC) and the American Heart Association
(AHA) . The NCEP guidelines utilized the Framingham Risk Score
(FRS) . However, the outcome was only CHD, and the population
this was derived from was completely White, and. Therefore, the work
groups who developed the ACC/AHA tool derived risk equations
from community-based cohorts that included African-Americans are
therefore were widely representative of the US population. They also
focused on estimating an individual’s first hard ASCVD event, defined
as first occurrence of nonfatal myocardial infarction, CHD death or fatal
or nonfatal stroke. This inclusion of stroke in the assessment of CVD
risk is consistent with evidence from a statement from the AHA and the
American Stroke Association . This tool is referred to as the ASCVD
Risk Estimator and again this risk estimator has not been used in the
The ASCVD Risk Estimator has been used in the general population
and compared to CACS. A retrospective study of 687 participants, average age 53.5+7.7 years, demonstrated a Kappa of 0.23+0.029,
indicating a low level of agreement. 65.6% of participants were placed
into the same risk category, but 13.8% had significant disagreement in
level of risk between the two risk assessment tools, defined as being in
the highest risk group by one risk assessment and in the lowest in the
other risk assessment . The authors came to a similar conclusion that
Lieberman et al. did which was that CACS may be beneficial in those
with an intermediate ASCVD risk. Since the ASCVD Risk Estimator
has replaced the NCEP Guidelines, a SCI study comparing the ASCVD
Risk Estimator and CACS should be done in order to determine their
applicability in the SCI population.
The Lieberman et al. article was published in 2011. It added to
the literature supporting CVD, and specifically CHD, as significant
diseases and potentially causes of mortality in the SCI population [6,7].
Following an acute SCI, there is a significant loss of skeletal muscle and
an increase in fat mass below the level of injury [8-11]. There is also
a decrease in sympathetic nervous system activity . As a result of
the decreased lean mass, decreased sympathetic nervous system activity,
and decreased physical activity, persons with SCI have decreased energy
expenditure compared to able-bodied individuals [13-15]. Subsequently,
obesity, and particularly central adiposity, is common among persons
with chronic SCI and is more prevalent than in able-bodied persons [16-
22]. The sedentary lifestyle can also result in low levels of high density
lipoprotein cholesterol (HDL-C), an additional CHD risk factor [23,24].
Many other articles had previously documented CHD risk factors
including diabetes mellitus [25,26], dyslipidemia [27,28], obesity [17,29] and inflammation [30,31]. Yet, a literature search of clinical trials
with the search terms (“spinal cord” or tetraplegia or paraplegia or
quadriplegia) AND (cardiovascular disease or coronary heart disease
or diabetes) only revealed two articles [32,33] with interventions aimed
to improve cardiovascular health or improve body composition. A
similar search with the same SCI terms along with exercise or nutrition
resulted in 169 studies. However, only 10 of these were geared towards
cardiovascular health or body composition changes. It will most likely
take many more diet and lifestyle and possibly medication intervention
studies aimed to reduce CHD risk factors, such as obesity, dyslipidemia
and diabetes mellitus, in individuals with chronic SCI in order to
develop mechanisms that can reduce the incidence of ASCVD in the
- Lieberman JA, Hammond FM, Barringer TA, Norton HJ, Goff DC, et al. (2011) Comparison of coronary artery calcification scores and National Cholesterol Education program guidelines for coronary heart disease risk assessment and treatment paradigms in individuals with chronic traumatic spinal cord injury. J Spinal Cord Med 34: 233-240.
- Goff DC, Jr, Lloyd-Jones D M, Bennett G, Coady S, et al. (2014). 2013 ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American college of cardiology/American heart association task force on practice guidelines. Circulation 129: S49-S73.
- Third Report of the National Cholesterol Education Program (NCEP) (2002) Expert panel on detection, evaluation and treatment of high blood cholesterol in adults (adult treatment panel iii) final report. Circulation 106: 3143-3421.
- Lackland DT, Elkind MS, D'Agostino R Sr, Dhamoon MS, Goff DC, et al. (2012) Inclusion of stroke in cardiovascular risk prediction instruments: A statement for healthcare professionals from the American heart association/American stroke association. Stroke 43: 1998-2027.
- Isma'eel H, Min D, Al-Shaar L, Hachamovitch R, Halliburton S, et al. (2016) Assessing level of agreement for atherosclerotic cardiovascular disease risk categorization between coronary artery calcium score and the american college of cardiology/American heart association cardiovascular prevention guidelines and the potential impact on treatment recommendations. Am J Cardiol 118: 1480-1485.
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- Modlesky CM, Bickel CS, Slade JM, Meyer RA, Cureton KJ, et al. (2004) Assessment of skeletal muscle mass in men with spinal cord injury using dual-energy X-ray absorptiometry and magnetic resonance imaging. J Appl Physiol 96: 561-565.
- Jones LM, Goulding A, Gerrard DF (1998) DEXA: A practical and accurate tool to demonstrate total and regional bone loss, lean tissue loss and fat mass gain in paraplegia. Spinal Cord 36: 637-640.
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