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After reading the ‘Coronary artery disease and hypertension in a non-selected spinal cord injury patient population,’ we are concerned with the authors’ methodological approach. In a
well-researched introduction, Aidinoff and colleagues1 comment on the uncertainty surrounding the prevalence of coronary artery disease (CAD) in individuals with chronic spinal cord injury
(SCI), rightly arguing that certain studies document high rates of stress test positivity, whereas others are relatively reassuring. They then present their own work, in which review of the
medical records of people with SCI revealed an essentially average risk of CAD. Studying CAD in people with SCI is critically important, but data stemming from medical record reviews and/or
patient interviews are fundamentally untrustworthy. First, most medical evaluations for CAD are precipitated by ‘typical’ or ‘atypical’ angina. As we have no idea how coronary ischemia feels
to people with absent or impaired sensation, how are we to know that people with SCI are being appropriately evaluated for even symptomatic heart disease? Second, chronic CAD—particularly
in the setting of collateral arterial flow—may not appear on electrocardiography or enzymatic analysis. Hence, although the authors argue that concern over underestimation of CAD can be
contradicted by their ‘relatively frequent routine ECG tracings and blood enzymes examination,’ even these scrupulous health-care providers may have missed clinically significant CAD. Third,
as we do not routinely screen people with SCI for arterial disease, we can easily imagine how physicians caring for injured individuals (and, hence, those individuals, themselves) may be
unaware of progressive and even accelerated atherogenesis. Finally, a recent study of Americans living with SCI revealed that 88% and 85.2%, respectively, had been examined by their
primary-care physicians while fully clothed and seated in their wheelchairs.2 It is clear, then, that many people with SCI receive inadequate physical examinations by their medical teams,
and that their likelihood of being assessed for slowed peripheral blood flow, vascular bruits or abdominal aneurysms (all of which may lead to evaluations for CAD) is quite low. A great many
studies purporting to describe rates of CAD among people with SCI utilize data that are inadequately objective and unmoored from patients’ actual anatomy. As heart disease emerges as one of
the lead causes of mortality in chronic SCI,3 our investigations and reporting must be both valid and clinically and physiologically meaningful. REFERENCES * Aidinoff E, Bluvshtein V,
Bierman U, Gelernter I, Front L, Catz A . Coronary artery disease and hypertension in a non-selected spinal cord injury patient population. _Spinal Cord_ (e-pub ahead of print 19 July 2016;
doi:10.1038/sc.2016.109). Article Google Scholar * Stillman MD, Frost KL, Smalley C, Bertocci G, Williams S . Health care utilization and barriers experienced by individuals with spinal
cord injury. _Arch Phys Med Rehabil_ 2014; 95: 1114–1126. Article Google Scholar * NSCISC. National Spinal Cord Injury Statistical Center Spinal Cord Injury Model Systems 2014. Annual
Report Complete Public Version. 2014. Available from: http://www.nscisc.uab.edu/PublicDocuments/reports/pdf/2014%20NSCISC%20Annual%20Statistical%20Report%20Complete%20Public%20Version.pdf
(accessed on 22 January 2016). Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA,
USA Michael D Stillman * Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA Michael D Stillman & Steve Williams * Texas, USA, Daniel
Graves Authors * Michael D Stillman View author publications You can also search for this author inPubMed Google Scholar * Steve Williams View author publications You can also search for
this author inPubMed Google Scholar * Daniel Graves View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to Michael D
Stillman. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no conflict of interest. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Stillman,
M., Williams, S. & Graves, D. ‘Problematic methodology’. _Spinal Cord Ser Cases_ 3, 16028 (2017). https://doi.org/10.1038/scsandc.2016.28 Download citation * Published: 04 May 2017 *
DOI: https://doi.org/10.1038/scsandc.2016.28 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable link is not
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