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Nontraditional CHD Risk Markers: How Much Value Do They Add?

Not much overall, according to data from the ARIC study

Traditional coronary heart disease (CHD) risk factors do not identify a substantial proportion of people who develop CHD, prompting interest in nontraditional markers for enhancing risk prediction. These researchers assessed the predictive value of 19 nontraditional markers, including C-reactive protein (CRP), among 15,792 participants (age 45–74) in the Atherosclerosis Risk in Communities (ARIC) study.

Many of the nontraditional markers, including CRP, showed independent associations with risk for incident CHD. According to a statistical parameter known as the area under the receiver operating characteristic curve (AUC), in which 1.0 reflects perfect diagnostic value and 0.5 reflects no diagnostic value, the AUC of traditional risk-factor assessment was about 0.8. Adding CRP data to the risk model improved the AUC by only 0.003, a nonsignificant addition. The only nontraditional marker that statistically significantly enhanced the traditional factors’ AUC was lipoprotein-associated phospholipase A₂, and it did so very modestly (by 0.006). Furthermore, adding nontraditional markers to the risk model did little to change the decile of CHD risk where patients fell according to traditional risk assessment.

Comment: Nontraditional risk markers had statistically significant independent associations with incident CHD, but they did very little to improve the predictive value of traditional risk-factor assessment. The authors and the editorialists conclude that because these novel markers do not meaningfully reduce misclassification by traditional risk scoring, they should not be used in basic risk-factor assessment. However, the current data do not rule out a role for markers such as CRP in improving risk prediction in selected patients, such as those with traditionally assessed CHD risk that is between intermediate and high. This type of selective role is supported by a recent Women’s Health Study analysis showing that use of CRP significantly improved risk prediction in nondiabetic women whose traditional 10-year CVD risk was at least 5% (Journal Watch Cardiology Aug 9 2006).

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology August 9, 2006

Citation(s):

Folsom AR et al. An assessment of incremental coronary risk prediction using C-reactive protein and other novel risk markers: The Atherosclerosis Risk in Communities study. Arch Intern Med 2006 Jul 10; 166:1368-73.

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• Medline abstract (Free)

Lloyd-Jones DM and Tian L. Predicting cardiovascular risk: So what do we do now? Arch Intern Med 2006 Jul 10; 166:1342-4.

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• Medline abstract (Free)