Could Levels ofCirculating Biomarkers ofInflammation Help Guide Therapy

A retrospective analysis of CRP levels in a large primary prevention trial, Air Force Coronary Atherosclerosis Project/Texas Coronary Atherosclerosis Project, suggested that apparently healthy individuals with below median LDL levels but above median hsCRP levels derived benefit from statin therapy (39). Curiously, individuals with both below median LDL and below median hsCRP levels did not benefit from treatment, indicating that promiscuous use of statins in primary prevention likely would not prove cost-effective and would expose one-fourth of the apparently healthy population to potential risks and expensive drug treatment without benefit.

This provocative post hoc analysis generated the intriguing hypothesis that one might identify apparently healthy individuals with below average LDL levels who nonetheless could benefit from statin therapy by assessing their inflammatory status, e.g., by measuring hsCRP. Despite its appeal, we currently lack prospective clinical trial evidence to support this change in practice. A large-scale, randomized clinical trial currently under way will test this hypothesis rigorously (40-42), and the results should shed light on the utility of inflammatory biomarkers as a guide for therapy in apparently healthy populations.

Some have proposed that assessment of inflammatory status might not only aid risk stratification but also provide a motivational tool for patients to change their modifiable risk factors such as smoking, diet, and physical activity. Although this concept has theoretical merit and acknowledges the vital importance of lifestyle in the modulation of cardiovascular risk, currently there is lack evidence that informing individuals of their inflammatory status will lead to sustained changes in behavior or modifiable risk factors. Indeed, in a military population, information regarding coronary calcium scores, a readily understandable putative risk marker, failed to yield behavioral change.

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