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Should We Use CRP to Target Patients for Statin Therapy?

Patients with elevated levels of the inflammatory marker C-reactive protein (CRP) are at higher risk for adverse coronary events than are patients whose CRP levels are not elevated. Recent data suggest that pravastatin reduces CRP levels independent of its effect on lipid levels. These researchers, one of whom holds a patent on the use of CRP in risk stratification, hypothesized that CRP levels could be effective in targeting patients for primary-preventive statin therapy. They analyzed data from 5742 participants enrolled in an industry-sponsored, randomized, primary-prevention trial of lovastatin versus placebo (JWC Aug 1998, p. 72, accession number 980710001, and JAMA 1998; 279:1615). All participants had average total-cholesterol levels and below-average HDL-cholesterol levels.

Baseline CRP level was an independent predictor of adverse coronary events (mean follow-up, 5 years): The higher the baseline CRP level, the greater the risk for events in the placebo group than in the lovastatin group. At 1 year, lovastatin treatment significantly reduced CRP levels (by 14.8 percent), independent of lipid-level effects. Predictably, lovastatin significantly lowered the rate of overall events at 5 years among participants with total-cholesterol to HDL-cholesterol ratios that were higher than the median. In addition, lovastatin significantly lowered 5-year event rates among participants with below-median cholesterol ratios and above-median CRP levels, and among those with above-median cholesterol ratios and below-median CRP levels. For participants with above-median cholesterol ratios and CRP levels, the reduction was nonsignificant; for those with below-median cholesterol ratios and CRP levels, lovastatin essentially had no effect.

Comment: For primary prevention, statin therapy appears to be as effective in people with elevated CRP levels as in people with elevated cholesterol levels, although the benefit is less clear in people with elevated levels of both. Nonetheless, the results point to a potential role for CRP in targeting patients for statin therapy and suggest that lipid lowering may have an anti-inflammatory component. Of course, the ultimate decision about statin use for primary prevention will require careful consideration of the risks, benefits, and costs of therapy.

— JM Gore

Published in Journal Watch Cardiology August 31, 2001

Citation(s):

Ridker PM et al for the Air Force/Texas Coronary Atherosclerosis Prevention Study Investigators. Measurement of C-reactive protein for the targeting of statin therapy in the primary prevention of acute coronary events. N Engl J Med 2001 Jun 28 344 1959-1965.

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