A new scientific statement on inflammation from the American College of Cardiology confirms the value of high-sensitivity C-reactive protein (hsCRP) in clinical decision-making by stressing the importance of universal screening of the biomarker in both primary and secondary prevention of cardiovascular disease.

The statement, published in the Journal of the American College of Cardiology, provides consensus recommendations for screening, evaluation, and risk assessment for cardiovascular disease; inflammatory biomarkers in cardiovascular imaging; inflammation inhibition in behavioral and lifestyle risks; and anti-inflammatory approaches in primary and secondary prevention, as well as in heart failure and other cardiovascular diseases. 

“The statement is very comprehensive, provides the state of the art, and is focused on practical clinical aspects, which should be sufficient for the practicing physician,” said Wolfgang Koenig, MD, PhD, a professor of medicine at the German Heart Centre of the TUM University Hospital in Munich, Germany, who was not involved in the writing of the statement.

Biomarkers for Cardiovascular Disease Risk Prediction

Many years have passed since the publication of a US comprehensive scientific statement on inflammation and heart disease, according to statement co-author Sumanth D. Prabhu, MD, chief of cardiology at the Washington University School of Medicine in St. Louis.

“For example, the US Centers for Disease Control and Prevention/American Heart Association workshop on inflammation and cardiovascular disease was in 2002,” Prabhu told Medscape Medical News. “Over that time, there have been multiple preclinical and clinical studies performed in atherosclerotic [disease] and other types of cardiovascular disease that have furthered our understanding of the importance of inflammation and how to detect and act upon it, while also shedding light on future studies that are needed.”

As a result of the ensuing decades of research, the authors of the current statement now recommend universal screening of hsCRP in both primary and secondary cardiovascular disease prevention, which they deemed “a major clinical opportunity.”

The authors said several other inflammatory biomarkers, such as interleukin-6, fibrinogen, and neutrophil-to-lymphocyte ratio, also predict risk, but their routine evaluation contributes little to hsCRP. Further, biomarkers to detect vascular inflammation are promising in research, they wrote, but should not be used in routine clinical settings.

In another recommendation, the statement noted that hsCRP level is at least as predictive of future events as low-density lipoprotein (LDL) cholesterol levels for patients with known cardiovascular disease, regardless of whether the patient is on statin therapy. 

The authors also emphasized the critical role of lifestyle interventions to reduce systemic inflammation; this includes regular exercise of at least 150 min/week, a focus on the Mediterranean diet or the Dietary Approaches to Stop Hypertension diet, and increasing the intake of omega-3 fatty acids. 

Application in Clinical Practice

Prabhu said he believes the scientific statement should lead to a broader use of hsCRP, and potentially other inflammatory markers, for practical risk prediction and an adjustment of management recommendations for patients, such as the early initiation of lifestyle interventions to reduce inflammatory risk based on hsCRP.

Koenig stressed that patients at risk for cardiovascular disease should be tested for an increased inflammatory burden by measuring hsCRP together with their LDL cholesterol. 

“Improved risk stratification may then lead to more intensive control of traditional cardiovascular risk factors and potentially anti-inflammatory treatment with colchicine. Other anti-inflammatory drugs are being investigated presently in phase 2 and 3 trials. This means you cannot only diagnose low-grade systemic inflammation, but it has also become actionable,” he said.

“The main hope,” Koenig continued, “is that physicians start measuring hsCRP routinely, which then would lead to a successful identification and treatment of the inflammatory burden and to a better prognosis of patients.”

With much of the existing research on inflammation and disease risk focusing on atherosclerotic disease, Prabhu noted that inflammation also plays a key role in the pathophysiology of other cardiovascular diseases, such as cardiometabolic disease, heart failure, and arrhythmias.

“We are in the early stages of our understanding as to how to appropriately therapeutically target inflammation in these disease scenarios,” he said. “This will no doubt be the focus of much future research.”

Prabhu reported having ownership/partnership/principal role with BioThera. Koenig reported serving as a consultant for Apontis Pharma and Novo Nordisk and having served on the steering committees for the CANTOS and COLCOT trials.

Brian Ellis is a freelance writer and editor who lives in Southwest Virginia.