Tuesday, January 28, 2003

New test of heart risk gains ground

CRP guidelines may help decide treatment

By Tim Bonfield
The Cincinnati Enquirer

People who get heart disease screening tests already know about their HDL and LDL cholesterol levels. Soon, millions of Americans also may be keeping track of their CRP levels.

CRP stands for C-reactive protein, a marker of inflammation found in the bloodstream that recent studies indicate may be even more important than cholesterol levels at predicting the risk of heart attacks and strokes.

New guidelines about when to conduct CRP tests and how to interpret the results were published today in Circulation, the journal of the American Heart Association.

They were developed jointly by the Centers for Disease Control and Prevention and the heart association.

"These are the first major recommendations about screening for heart disease to come out in about 20 years," said Dr. Dean Kereiakes, a Cincinnati cardiologist who wrote an editorial in Circulation that accompanied the recommendations. "This signifies that this concept has really arrived."

Heart disease is the nation's No. 1 killer, causing more than 945,000 deaths a year nationwide, according to the heart association.

Some doctors already use the CRP test.

But many cardiologists have not made CRP testing a common practice.

"I think that will change fairly quickly," Dr. Kereiakes said.

The test reflects systemic inflammation that can come from many sources, including excess weight, infections, trauma, even gum disease.

Doctors say the inflammation weakens the walls of blood vessels and can cause the body to absorb LDL, or bad cholesterol, at higher rates. The inflammation also can break open fatty buildups inside blood vessels, allowing particles to flow downstream to trigger heart attacks or strokes by blocking smaller artery branches.

The guidelines call for performing the CRP test on people judged to be at 10 percent to 20 percent increased risk of heart disease over the next 10 years, based on age, high cholesterol, high blood pressure and family history.

This category includes an estimated 40 percent of U.S. adults.

However, even in these patients, the test is considered optional and should be used only if it will help doctors decide whether they need treatment.

Labs and hospitals charge between $10 and $120 to perform the test, which measures CRP in micrograms per milliliter of blood.

Levels less than 1 would be considered "low"; 1 to 3 would be "moderate"; 3 to 10 would be "high" and above 10 would be "very high."

The significance of the CRP test is that it can reveal signs of increased heart attack risk before people develop high cholesterol levels, which would allow people to take steps sooner to reduce their risks, Dr. Kereiakes said.

For some people, elevated CRP levels can be reduced by lifestyle changes, such as losing weight, increasing exercise and quitting smoking. For those with diabetes, carefully controlling blood-sugar levels also can help.

The debate gets more intense over how quickly doctors should step in with prescriptions for anti-inflam- matory drugs. A wide range of medications can reduce CRP levels, including aspirin, ACE inhibitors, statins and COX-2 inhibitors.

For some diabetics, an elevated CRP level may be a tipping point for more aggressive treatment, such as having an insulin pump implanted, Dr. Kereiakes said.

For people in their 30s and 40s who have a family history of early heart attacks but no signs of cardiac disease themselves, an elevated CRP level could justify using medications that traditionally aren't prescribed until much later in the disease process, he said.

The guidelines urge against testing people at very low risk, since those patients would probably not be put on treatment even if inflammation were found, as well as those already diagnosed with heart disease, since they should already be getting inflammation-controlling medications.

"The guidelines are very much oriented toward coming up with numbers that would alter your or your patients' behavior," said Dr. Thomas Pearson of the University of Rochester, co-chairman of the committee that wrote the statement.

Much of the evidence backing the importance of inflammation in heart disease comes from the research of Dr. Paul Ridker of Boston's Brigham and Women's Hospital.

One of his latest studies, conducted on women, found that half of all heart attacks and strokes occur in people with seemingly safe cholesterol levels, and that women with high CRP levels have double the risk of those with low levels.

The Associated Press contributed to this story.

E-mail tbonfield@enquirer.com

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