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C-Reactive Protein for Cardiovascular Risk Assessment

Department of Medicine, King Abdul Aziz Medical City, Jeddah, Kingdom of Saudi Arabia

Address correspondence to Dr. Mona A. Kholeif, Consultant Cardiologist, Cardiology Section, Department of Medicine, King Abdul Aziz Medical City, P.O. Box 9515, Jeddah 21423, Kingdom of Saudi Arabia. E-mail: kholeifm{at}ngha.med.sa

Malik et al. (1) report on the usefulness of C-reactive protein (CRP) in stratifying risk in patients with the metabolic syndrome and diabetes.

Studies on normal volunteers showed intraindividual variability, which in 50% of individuals was sufficient to change their CRP-related risk category (2).

Bogaty et al. (3) have also demonstrated what seems to be spontaneous fluctuation of CRP in stable patients with coronary artery disease (CAD).

Intraindividual biological variation data for high-sensitivity CRP (hsCRP) needs to be established for each individual before using the level to estimate risk and prognosis.

Reliance on single or even the mean of two measurements 2–4 weeks apart is clearly unacceptable, and there is conflict in the published literature regarding the number of samples that should be tested and the time span (3).

Many laboratories use conventional CRP assays, which report levels <5 mg/l as normal. These assays are obviously unsuitable for risk assessment, as it now seems that levels as low as 2 mg/l confer additional risk (3,4). Laboratories should be able to provide hsCRP assays for the purpose of cardiovascular risk stratification.

CRP seems to be an important player in the inflammatory component of atherosclerosis and an independent predictor of adverse CAD outcomes (5,6). Adding it formally to risk stratification scoring methods would improve our ability to identify high-risk patients in both primary and secondary prevention. Before adopting this strategy, it is important to decide how many measurements should be checked, over what interval, and under what conditions.

Also, what weight should be given to the presence of an elevated CRP? Should it influence risk scores qualitatively, like diabetes, or quantitatively, like systolic blood pressure and cholesterol; the higher the level, the higher the risk? How should CRP level be incorporated into standard scoring systems such as the Framingham risk score?

Until these issues are addressed, CRP measurements should perhaps be reserved for problematic or borderline cases, where the decision to use an intervention, whether medical or procedural, is difficult.

References

1. Malik S, Wong ND, Franklin S, Pio J, Fairchild C, Chen R: Cardiovascular disease in U.S. patients with metabolic syndrome, diabetes, and elevated C-reactive protein. Diabetes Care 28:690–693, 2005[Abstract/Free Full Text]
   
2. de Maat MPM, de Bart ACW, Hennis BC, Meijer P, Havelaar AC, Mulder PG, Kluft C: Interindividual and intraindividual variability in plasma fibrinogen, TPA antigen, PAI activity, and CRP in healthy, young volunteers and patients with angina pectoris. Arterioscler Thromb Vasc Biol 16:1156–1162, 1996[Abstract/Free Full Text]
   
3. Bogaty P, Brophy JM, Boyer L, Simard S, Joseph L, Bertrand F, Dagenais GR: Fluctuating inflammatory markers in patients with stable ischemic heart disease. Arch Intern Med 165:221–226, 2005[Abstract/Free Full Text]
   
4. Ridker PM, Cannon CP, Morrow D, Rifai N, Rose LM, McCabe CH, Pfeffer MA, Braunwald E, for the Pravastatin or Atorvastatin Evaluation and Infection Therapy –Thrombolysis in Myocardial Infarction 22 (PROVE IT –TIMI 22) Investigators: C-Reactive protein levels and outcomes after statin therapy. N Engl J Med 352:20–28, 2005[Abstract/Free Full Text]
   
5. Danesh J, Pepys MB: C-reactive protein in healthy and in sick populations. Eur Heart J 21:1564–1565, 2000[Free Full Text]
   
6. Ehrenstein MR, Jury EC, Mauri C: Statins for atherosclerosis: as good as it gets? N Engl J Med 352:73–75, 2005[Free Full Text]
   

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				N. D. Wong and S. Malik C-Reactive Protein for Cardiovascular Risk Assessment in the Metabolic Syndrome Diabetes Care, October 1, 2005; 28(10): 2598 - 2599. [Full Text] [PDF]

This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kholeif, M. A. Search for Related Content PubMed PubMed Citation Articles by Kholeif, M. A. Social Bookmarking                What's this?