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Brief Communication
High sensitivity C reactive protein and
cardiovascular disease risk. Velasco. Cuba. 2011
 

Jorge B. Vega Abascal1; Mayra R. Guimará Mosqueda2;
Luis A. Vega Abascal2;  Yaneisi García Bermúdez2

1. Velasco Universitary Policlinic.
Teaching and Research Department. Velasco, Holguín, Cuba.
2. Holguin Teaching Hospital.  Cardiology Department.  Holguín, Cuba .


Abstract
C reactive protein is a non specific marker of inflammation and a predictor of incident coronary heart disease, cardiovascular disease and subclinical vascular disease; even though it remains controversial if c reactive protein provides significant prognostic insight over and above other traditional risk factors.
Objective: To evaluate the utility of high sensitivity c reactive protein (hs CRP) in the assessment of cardiovascular risk in primary health care.
Methods: The study sample was 168 participants aged between 34-75 years (mean age 52 years, 65 % women) free of cardiovascular disease, the cardiovascular risk was stratified through the determination of hs CRP, according to recommendations of the AHA / CDC as low risk if < 1 mg/ l, between 1-3 mg/ l as intermediate risk and > 3 mg/ l as high risk and compared with the coronary and global cardiovascular risk calculated by the Framingham- Wilson risk score(1998) and the Framingham- D´Agostino risk score(2008) respectively, the correlation coefficient among hs CRP and the cardiovascular risk was calculated, the cardiovascular risk was re-stratified according to hs CRP concentration.
Results: The 54.2 % of the cases were hypertensive, a 20.2 % were smokers and 13.1 % were diabetics, the mean of high sensitivity c reactive protein was 2.81±2.60, the correlation coefficient between level of hs CRP and cardiovascular risk calculated was 0.178 (p 0.11) for coronary heart disease risk and 0.189 (p 0.007) for global cardiovascular risk, when re-stratified the cardiovascular risk calculated according to the risk obtained by means of hs CRP concentration, the 12.1 % of participants were reclassified as intermediate risk and the 5.1% as high risk.
Conclusion: The hs CRP determination is useful in the preventive decision making due that contributed to improve the prediction of cardiovascular risk calculated with the specific risk table.

 

Introduction
Cardiovascular disease are the principal deadly cause all over the world, every year more people die due to  cardiovascular disease than for any other causes [1], the heart and cerebral vascular diseases constituted the first and third fatal cause in Cuba in the year 2010, resulting in 33 559 deceases, that represents the 36. 8 % of the total of deceases [2].

C reactive protein is a non specific marker of inflammation and a predictor of incident coronary heart disease, cardiovascular disease and subclinical vascular disease, the available evidence suggests that a moderate increase in the high sensitivity c reactive protein concentration increase the risk of myocardial infarction and cerebral vascular disease [3]. The primary prevention of cardiovascular disease puts in the center of the control of risk factors, elements correlated to the incidence and mortality by theses illnesses, the best tool to establish priorities in primary prevention is the exact assessment of the risk to develop them, the more precise and valid establishment of a function for risk prediction will increase the scientific base for the decision making related with the primary prevention of cardiovascular diseases [4, 5].

The c reactive protein and other biomarkers of inflammation and oxidation has proposed as candidate factors to improve the cardiovascular risk, his paper would be able to be relevant due to the inflammatory  component of these diseases, even though it remains controversial if c reactive protein provides significant prognostic insight over and above other traditional risk factors [6].


Objective
To evaluate the utility of high sensitivity c reactive protein (hs CRP) in the assessment of cardiovascular risk in primary health care.


Methods
The study sample was 168 participants aged between 34-75 years (mean age 52 years, 65% women), in the Velasco Teaching Policlinic, to January from June 2011, free of cardiovascular disease, the cardiovascular risk was stratified through the determination of hs CRP, according to recommendations of the AHA / CDC [7] as low risk if < 1 mg/ l, between 1-3 mg/ l as intermediate risk and > 3 mg/ l as high risk  and compared with  the coronary  and  global cardiovascular risk calculated by  the Framingham- Wilson risk score(1998) [8]  and the Framingham- D´Agostino risk score (2008) [9] respectively, the correlation coefficient among hs CRP and the cardiovascular risk was calculated, the cardiovascular risk was re-stratified according to hs CRP concentration.


Results
The 54.2% of the cases were hypertensive, a 20.2% were smokers and 13.1% were diabetics, the mean of high sensitivity c reactive protein was 2.81±2.60 (Table 1),the prediction of coronary risk was 59.9% as low risk (< 10%), the 27% as intermediate risk(10-20%) and  the 13,1% as high risk (> 20%), the global cardiovascular risk were  47%, the 27.4% and the 25,6% as low, intermediate and high risk respectively (Graphic 1), the correlation coefficient between level of hs CRP and cardiovascular risk calculated was 0.178 (p 0.11) for coronary heart disease risk and 0.189 (p 0.007) for global cardiovascular risk (Table 2), when re-stratified the cardiovascular risk calculated according to the risk obtained by means of hs CRP concentration,  the 12.1% of participants were reclassified as intermediate risk and the 5.1% as high risk (Graphic 2).

Table 1. Characteristics of the population


Graphic 1. Prediction of coronary and cardiovascular risk according to risk tables


Table 2. Mean of high sensitivity c reactive protein  according to cardiovascular risk category


Graphic 2.  Cardiovascular risk reclassification according to the levels of high sensitivity c reactive protein


Discussion
The cardiovascular risk prediction has become the cornerstone the clinical practice guidelines for the global management of risk factors at clinical practice, the cardiovascular risk establishes the probability to suffer a cardiovascular episode in a determined period of time, generally 5 or 10 years [10].

The Framingham risk score provide an useful measure for coronary heart disease and cardiovascular disease stratification and they have been of value in clinical practice [11], however, in spite of the success of models, up to 20% of all of the coronary events it occurs in absence of any traditional risk factors and the patients have been classified as moderate risk and the smallest discriminating capability of these factors is shown [4], besides  most of the people that do not develop coronary heart disease,  have  less clinically elevated a Framingham risk factor [10,11], it comes in handy to recognize that this tool never will be perfect in identification of high risk patients and we  will always  talk about probabilities, since there are patients  with multiple risk factors that they never will suffer a cardiovascular events and another without no risk factors of  habitually included in the table, that definitely will shown a cardiovascular disease [11].

In any population it is very elevated the number of persons with low or moderate risk (generally over 50%), in this group will produce a great proportion of cardiovascular events [5] and for the little sensibility of risk functions, it has been proposed to incorporate another risk factors and biomarkers to improve the prediction risk [12], like high sensitivity c reactive protein, which associates to an increase risk of cardiovascular disease, diabetes and even hypertension [13].

The measure of endothelial function may have prognostic value for the prediction of cardiovascular events, improving the cardiovascular risk prediction  in both sex, the association among endothelial dysfunction and atherosclerosis classical risk factors has been suggested,  as  age, diabetes, hypertension, smoking, dyslipidemia, that give supports the concept that endothelial dysfunctionmay be regarded as “an integrated risk of risk factors”, indicating that it could serve as a highly sensitive marker for the overall cardiac risk of an individual, a no direct measures of endothelial function is the determination of high sensitivity c reactive protein [14].

The Framingham risk score for the prediction of coronary risk and global cardiovascular risk was utilized in the research, the correlation coefficient among global cardiovascular risk and hs CRP level was statistically significant, and however, increasingly often we talk of total or global cardiovascular risk given that coronary heart disease is only a part of atherosclerotic disease, which also includes cerebral vascular disease and peripheral artery disease [5].

One of principal limitations of tables is its application to concrete different populations of population of origin, however, the risk  functions are system preferred of screening of cardiovascular risk [12], the risk functions include age, sex, smoking total and HDL cholesterol, diabetes and hypertension, available variable in the primary health care, it is possible that a best stratification of risk may be obtained most of all in the groups that produce more uncertainty (low or intermediate groups), where the majority of cardiovascular events was concentrated, Incorporating clinical complementary information like the CPR hs determination [12,13].

While the necessary information for each new factor is generated, would be able to consider, from the clinical view point, the presence of one or more no traditional risk factors like useful elements about the decision making on the intervention intensity that would be done in the subjects classified in moderate or intermediate risk, to re-classify to a high risk category or inclusively toward an inferior risk category, in absence of subclinical atherosclerotic can be reasonable [12, 13].


Conclusion

The hs CRP determination is useful in the preventive decision making due that contributed to improve the prediction of cardiovascular risk calculated with the specific risk table.

 

BIBLIOGRAPHY

  1. WHO Media centre/ Enfermedades cardiovasculares. New York. [Actualizado enero 2011, citado julio 2011]. Disponible en: http://www.who.int/mediacentre/factsheets/fs317/es/index.html
  2. Anuario estadístico de salud en Cuba.2010. [Actualizado 2 de abril de 2011, citado: 2 de julio 2011]. Disponible en: http://files.sld.cu/dne/files/2011/04/anuario-2010-e-sin-graficos1.pdf
  3. Dhingra R, Philimon G, Byung-Ho N,  D’Agostino R B , WilsonP W, Benjamin E J, et al. C - reactive protein, Inflammatory Conditions and Cardiovascular Disease Risk. Am J Med. 2007 December; 120(12): 1054–1062. doi: 10.1016/j.amjmed.2007.08.037. PubMed Central PMCID: PMC2215387.
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  6. Melander O, Newton-Cheh C,  Almgren P, Hedbland B, Berglund G, Engstrom G, et al. Novel and conventional biomarkers for the prediction of incident cardiovascular events in the community. JAMA. 2009 July 1; 302(1): 49–57. doi:10.1001/jama.2009.943. Disponible en: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066521/?tool=pmcentrez
  7. Myers GL, Rifai N, Tracy RP, et al. CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: Report From the Laboratory Science Discussion Group. Circulation. 2004; 110:e545–e549. [PubMed] http://www.ncbi.nlm.nih.gov/pubmed/15611379
  8. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998; 97; 1837-47. Disponible en: http://circ.ahajournals.org/cgi/content/full/97/18/1837
  9. D'Agostino R, Vasan RM, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care. The Framingham Heart Study. Circulation. 2008; 117:743-53.Disponible en: http://circ.ahajournals.org/cgi/content/full/117/6/743
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    =&pident_revista=25&ty=20&accion=L&origen=elsevier&web=www.revespcardiol.org&lan=es&fichero=25v64n05a90003647pdf001.pdf
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  14. Bacon S, Lavoie K, Arsenault A, Dupuis J, Pilote L, Laurin C, et al. The Research on Endothelial function in Women And men at Risk for cardiovascular Disease (REWARD) Study: Methodology.BMC Cardiovascular Disorders 2011, 11:50 doi: 10.1186/1471-2261-11-50. Disponible en: http://hinari-gw.who.int/whalecomwww.biomedcentral.com/whalecom0/content/pdf/1471-2261-11-50.pd

 

 

 

 

 



Publicación: Septiembre 2011

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