Should statin therapy be considered for patients with elevated C-reactive protein? The need for a definitive clinical trial

Should statin therapy be considered for patients with elevated C-reactive protein?The need for a definitive clinical trialClinical trials demonstrate that HMGCoA reductase inhibitors reduce the risk of first cardiovascular events 1,2 .However, better screening methods are needed in primary prevention to detect high risk individuals for whom the number needed to treat is small enough to make prophylactic statin therapy cost-effective.Although LDL screening improves cost-effectiveness of statins in some primary prevention settings, this approach is incomplete as nearly half of all coronary events occur among persons without overt hyperlipidaemia 3,4 .In an effort to improve vascular risk detection, many physicians have considered screening for C-reactive protein (CRP), an inflammatory biomarker associated with increased risk of myocardial infarction, stroke and peripheral arterial disease 56789 .Such a combined lipid plus CRP screening approach has intuitive appeal, in part because CRP predicts future vascular risk even among those with low to normal lipid levels.Further, as statin therapy lowers CRP in an LDL independent fashion 10,11 , it has been hypothesized that CRP screening might provide a novel method to improve the targeting of statin therapy, particularly among those with low to normal levels of LDL cholesterol.This important hypothesis was addressed in a recent analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/ TexCAPS) 12 .In brief, AFCAPS/TexCAPS was a randomized, double-blind, placebo-controlled trial of lovastatin in the primary prevention of cardiovascular events conducted among 6605 American men and women with average cholesterol levels and below average HDL levels.Individuals with uncontrolled hypertension, secondary hyperlipidaemia, diabetes requiring insulin, or morbid obesity were excluded.Following randomization to either lovastatin or matching placebo, participants were followed over an average period of 52 years for the occurrence of first acute coronary events, prospectively defined as fatal or non-fatal myocardial infarction, unstable angina, or sudden cardiac death.