I agree with Dr. Modest that considerable evidence suggests that HDL cholesterol level is an important risk factor in predicting cardiovascular risk, but I disagree that it was a "glaring omission" in our paper. Space constraints prevented us from discussing details of each cardiovascular risk factor, but our paper highlighted the critical importance of overall cardiovascular risk, mentioned the complexities of risk factor interactions, and included references that discuss HDL cholesterol effects in detail (1, 2). However, although we agree that HDL cholesterol level is an important independent risk factor, we could find no clinical evidence meeting our inclusion criteria (valid epidemiologic evaluations in patients with LDL cholesterol levels <3.36 mmol/L [<130 mg/dL]) of whether HDL cholesterol is more important than any other cardiovascular risk factor in predicting the benefits of statin therapy. Future work should examine whether HDL cholesterol is important simply because it is one of many risk factors or whether there are HDL cholesterol–specific interaction effects.

We disagree with Dr. Ravnskov's assessment that substantial clinical evidence suggests that harmful effects are related to achieving very low LDL cholesterol levels. As we stated in our paper: "Our point is not that there is strong evidence against the current recommendations; it is that there is no valid clinical evidence to suggest that using treatments other than statins to pursue proposed LDL cholesterol goals is safe or effective." We hope that our study will stimulate those with access to the clinical trial data to more rigorously assess these questions by using the methodological approaches outlined in our paper.