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C-reactive protein improves risk prediction in patients with acute coronary syndrome, or does it?

Juan Carlos Kaski
DOI: http://dx.doi.org/10.1093/eurheartj/ehp435 274-277 First published online: 23 October 2009

Patients with acute coronary syndrome (ACS) represent a heterogeneous population. Both the severity of coronary artery disease and the extent of myocardial damage can differ markedly among patients presenting with ACS and these differences—in addition to age, left ventricular dysfunction, and the presence of co-morbidities—are likely to be responsible for different clinical outcomes in different patients. Accurate risk stratification of ACS patients continues to represent a major challenge to the managing physician.1,2 Established cardiovascular risk factors have been incorporated into algorithms for risk assessment in ACS patients and several clinical risk scores have been proposed in the past decade, which are promoted by International guidelines for management of patients with ACS.1,3 The Platelet glycoprotein IIb/IIIa in Unstable Angina: Receptor suppression Using Integrilin Therapy (PURSUIT),4 the Thrombolysis in Myocardial Infartion (TIMI),5 and the Global Registry of Acute Cardiac Events (GRACE)6 risk scores appear to be efficient prognostic indicators. However, they have limitations and physicians do not appear to have fully embraced the use of these scores in clinical practice.7,8 There is interest in the use of newer biomarkers, particularly those that have been shown to have independent prognostic value in different patient subgroups with coronary artery disease.9,10 The advent of biomarkers of inflammation, in particular high-sensitivity C-reactive protein, raised new hopes regarding improved prognostic algorithms in ACS.11 It has been speculated that the addition of C-reactive protein to other clinical variables encompassed by different risk scores can increase the prognostic ability of these clinical risk scores. In the general population, the use of a multimarker approach in different studies resulted in better risk prediction compared with single markers (Figure 1).12 In the Wang et al. study12 in over 3000 people attending the …

*Corresponding author. Tel: +44 208 725 2628, Fax: +44 208 725 3328, Email: jkaski{at}sgul.ac.uk