C-reactive protein: risk assessment in the primary prevention of atherosclerotic disease. Has the time come for including it in the risk profile?

About half of patients presenting with myocardial infarction do not have the "classic" risk factors. This has stimulated a search for other factors that may be responsible and, when present, may help to predict which patients are at greatest risk for myocardial infarction and other cardiovascular events. With improved understanding of the pathogenesis of ischemic cardiovascular disease, we have gleaned new insights into potential markers of underlying atherosclerosis and cardiovascular risk. In recent years, data suggesting that certain markers of inflammation--both systemic and local--play a key role in the development and progression of atherosclerosis, and in its final clinical complications have accumulated. Specifically, elevated levels of one systemic marker of inflammation, C-reactive protein (CRP), are associated with an increased risk of cardiovascular disease events. Among several markers of systemic inflammation, CRP shows the strongest associations with vascular events, and the addition of CRP to total cholesterol dramatically improves risk prediction. CRP fulfils most of the requirements needed to serve as a new risk factor, but still several issues await further confirmation and clarification before this marker can ultimately be included in the routine risk profile. Moreover, potentially important associations have been established between elevated CRP levels and increased efficacy of established therapies, in particular lipid-lowering therapy with statins; CRP testing may enable us to tailor expensive cardiovascular medication to the individual patient. Such an improved prescription strategy might be especially valuable in the primary care setting where the absolute cardiovascular risk is considerably lower compared to that in secondary prevention.