Thursday, October 4, 2012

CRP + Fibrinogen: That Extra Edge Against Heart Disease

We're all looking for that extra edge, that little bit that will get us in front of the competition & help us win.  Sometimes we don't condone that something extra, like performance enhancing drugs, while at other times we do, like Gordon Gekko in Wall Street & Wall Street 2: Money Never Sleeps.  Currently, we use a heart disease risk calculator based upon the Framingham Heart Study as espoused by the Adult Treatment Panel III.  However, its accuracy leaves much to be desired.

Therefore, some physicians have turned to the Reynolds Risk Score to gain additional sensitivity by adding CRP & family history to the variables used originally, eg sex, age, total & HDL cholesterol, systolic blood pressure & smoking status.  Still others have turned towards other biomarkers such as LP-PLA2, cholesterol particle numbers & size, etc.

But as much as I attempt to stay on the cutting edge (not the bleeding edge, mind you!), I don't find myself ordering these additional tests and more in most patients.  Why?  Because they haven't even reached their baseline goals, eg LDL-C less than 160md/dL for those at low 10 year risk of heart disease, much less those at highest risk who have not yet reached an LDL of <70mg/dl. 

 In other words, as I teach the residents, order tests because the results will guide/affect your decision making process.  Don't order tests just because you can!  Well, in a meta-analysis or 52 prospective studies involving 246,669 participants published in today's New England Journal of Medicine, the authors concluded that the additional testing of CRP & fibrinogen in those patients w/o known heart disease but deemed to be at intermediate risk of 10-20% over the next 10 years would prevent one additional event for every 400-500 people tested.

But note that the authors are not recommending that everyone have his/her CRP & fibrinogen tested, just those free of heart disease but at intermediate risk, as this additional information would help further stratify risk.  So don't fall prey to ordering tests just because you can.  Before you run, you first learn to walk.  Likewise, before ordering that CRP & fibrinogen, make sure you've met & exceeded your LDL goals.

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